Healthcare Provider Details

I. General information

NPI: 1437349479
Provider Name (Legal Business Name): DAVID MICHAEL WALLACE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 02/27/2020
Certification Date: 02/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22001 SOUTHWEST FWY STE 300
RICHMOND TX
77469-7001
US

IV. Provider business mailing address

4911 SANDHILL DR
SUGAR LAND TX
77479-5320
US

V. Phone/Fax

Practice location:
  • Phone: 281-633-4940
  • Fax: 281-633-4943
Mailing address:
  • Phone: 281-238-7870
  • Fax: 281-633-4985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34-008872
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberN0539
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: