Healthcare Provider Details

I. General information

NPI: 1124005566
Provider Name (Legal Business Name): ARNOLD WALLACE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 HIGHWAY 59 LOOP N
WHARTON TX
77488-7807
US

IV. Provider business mailing address

714 FM 1960 RD W SUITE 206
HOUSTON TX
77090-3405
US

V. Phone/Fax

Practice location:
  • Phone: 979-532-2500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberE4745
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: