Healthcare Provider Details

I. General information

NPI: 1649609728
Provider Name (Legal Business Name): JUSTIN K WALLACE D.V.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2013
Last Update Date: 11/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 S 6TH ST
CHICKASHA OK
73018-3420
US

IV. Provider business mailing address

120 S 6TH ST
CHICKASHA OK
73018-3420
US

V. Phone/Fax

Practice location:
  • Phone: 405-224-8023
  • Fax: 405-224-8024
Mailing address:
  • Phone: 405-224-8023
  • Fax: 405-224-8024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174M00000X
TaxonomyVeterinarian
License Number5380
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: