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General NPI Number Information
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NPI Number | 1184842627
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Entity Type | Individual
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Provider Name | WILLIAM ARTHUR WALLACE JR. M.D.
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Gender | Male
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Dates
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Enumeration Date | 04/22/2007
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Last Update Date | 11/01/2015
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Provider Practice Location Address
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Address Line | 1679 EAGLE HARBOR PKWY SUITE C
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City | FLEMING ISLAND
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State | FL
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Zip | 32003-4815
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Country | US
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Telephone | 904-348-0727
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Fax | 904-621-9272
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Provider Business Mailing Address
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Address Line | 1679 EAGLE HARBOR PKWY SUITE C
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City | FLEMING ISLAND
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State | FL
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Zip | 32003-4815
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Country | US
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Telephone | 904-348-0727
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Fax | 904-621-9272
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0122X
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Taxonomy Name | Plastic and Reconstructive Surgery Physician
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License Number | ME107749
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 2086S0122X
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Taxonomy Name | Plastic and Reconstructive Surgery Physician
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License Number | 35.079632
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License Number State | OH
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