Healthcare Provider Details

I. General information

NPI: 1851470033
Provider Name (Legal Business Name): DOUGLAS CHARLES WALLACE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 12/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 ST FRANCIS WAY STE 201
LAFAYETTE IN
47905-4923
US

IV. Provider business mailing address

3900 ST FRANCIS WAY STE 201
LAFAYETTE IN
47905-4923
US

V. Phone/Fax

Practice location:
  • Phone: 765-446-7981
  • Fax: 765-446-7982
Mailing address:
  • Phone: 765-446-7981
  • Fax: 765-446-7982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberG66727
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number036-101410
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number01071946A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: