Healthcare Provider Details

I. General information

NPI: 1770504888
Provider Name (Legal Business Name): HAROLD JAMES WALLACE III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE FLETCHER ALLEN HEALTH CARE DEPT. OF RADIATION ONCOLOGY
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-3506
  • Fax: 802-847-2386
Mailing address:
  • Phone: 800-847-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number308258
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number042-0009975
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: