Healthcare Provider Details

I. General information

NPI: 1780614529
Provider Name (Legal Business Name): ERIC LEE WALLACE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 W 4TH ST STE 201
COOKEVILLE TN
38501-2476
US

IV. Provider business mailing address

140 W 7TH ST
COOKEVILLE TN
38501-1726
US

V. Phone/Fax

Practice location:
  • Phone: 931-783-5515
  • Fax: 931-783-5513
Mailing address:
  • Phone: 931-783-5515
  • Fax: 931-783-5513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number71205
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: