Healthcare Provider Details

I. General information

NPI: 1881794162
Provider Name (Legal Business Name): JAMES HOWARD WALLACE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 22ND AVE FL 3
MERIDIAN MS
39301
US

IV. Provider business mailing address

350 N HUMPHREYS BLVD
MEMPHIS TN
38120-2177
US

V. Phone/Fax

Practice location:
  • Phone: 601-693-1055
  • Fax: 601-482-5312
Mailing address:
  • Phone: 901-227-8693
  • Fax: 901-227-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberT-2618
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number25034
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: