Healthcare Provider Details

I. General information

NPI: 1295749000
Provider Name (Legal Business Name): LESTER B. WALLACE JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 02/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1718 E 4TH ST SUITE 201
CHARLOTTE NC
28204-3261
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-0560
  • Fax: 704-384-0561
Mailing address:
  • Phone: 704-384-0560
  • Fax: 704-384-0561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number21891
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: