Healthcare Provider Details

I. General information

NPI: 1043253867
Provider Name (Legal Business Name): WALLACE R JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9175 GUILFORD RD STE 140
COLUMBIA MD
21046-1849
US

IV. Provider business mailing address

9175 GUILFORD RD STE 300
COLUMBIA MD
21046-2565
US

V. Phone/Fax

Practice location:
  • Phone: 410-512-9202
  • Fax: 949-991-1377
Mailing address:
  • Phone: 410-512-9122
  • Fax: 949-991-1359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0005X
TaxonomyHypertension Specialist Physician
License NumberD38086
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: