Healthcare Provider Details

I. General information

NPI: 1164408043
Provider Name (Legal Business Name): JEANNE WALLACE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 02/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 WALNUT HILL LN
DALLAS TX
75231-4426
US

IV. Provider business mailing address

7557 RAMBLER RD SUITE 706
DALLAS TX
75231-4142
US

V. Phone/Fax

Practice location:
  • Phone: 214-345-6789
  • Fax:
Mailing address:
  • Phone: 214-369-0800
  • Fax: 214-378-5311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG4871
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: