Healthcare Provider Details

I. General information

NPI: 1689648636
Provider Name (Legal Business Name): WALLACE JACKSON CHAMPLAIN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E DOWNING ST STE 208
TAHLEQUAH OK
74464-3234
US

IV. Provider business mailing address

1500 E DOWNING SUITE 208
TAHLEQUAH OK
74464-3363
US

V. Phone/Fax

Practice location:
  • Phone: 918-456-2496
  • Fax: 918-456-7108
Mailing address:
  • Phone: 918-456-2496
  • Fax: 918-456-7108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number1994
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100118860A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: