Healthcare Provider Details

I. General information

NPI: 1518129733
Provider Name (Legal Business Name): ADAM JOSEPH WALLACE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2008
Last Update Date: 04/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3336 E 32ND ST STE 220
TULSA OK
74135-4442
US

IV. Provider business mailing address

6802 S OLYMPIA AVE SUITE 100
TULSA OK
74132-1823
US

V. Phone/Fax

Practice location:
  • Phone: 918-255-7246
  • Fax: 918-255-7000
Mailing address:
  • Phone: 918-447-9300
  • Fax: 918-447-9308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number26497
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: