Healthcare Provider Details

I. General information

NPI: 1275539603
Provider Name (Legal Business Name): WILLIAM J WALLACE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 06/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 SHERIDAN SQ
KINGSPORT TN
37660
US

IV. Provider business mailing address

5 SHERIDAN SQ
KINGSPORT TN
37660-7390
US

V. Phone/Fax

Practice location:
  • Phone: 423-246-8155
  • Fax: 246-246-8658
Mailing address:
  • Phone: 423-246-8155
  • Fax: 246-246-8658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number01428
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: