Healthcare Provider Details

I. General information

NPI: 1619968146
Provider Name (Legal Business Name): DAVID RICHARD WALLACE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2903 1ST AVE
LAKE CHARLES LA
70601-8809
US

IV. Provider business mailing address

2903 1ST AVE
LAKE CHARLES LA
70601-8809
US

V. Phone/Fax

Practice location:
  • Phone: 337-478-6480
  • Fax: 337-474-9637
Mailing address:
  • Phone: 337-478-6480
  • Fax: 337-474-9637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number015614
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: