=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730490277
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES DAVID WALLACE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2010
-----------------------------------------------------
Last Update Date | 08/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34800 BOB WILSON DR
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92134-1894
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-532-7575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | BLDG H 2005 KNIGHT LANE ATTN: MEDICAL STAFF SERVICES
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32212-0140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | MD60918669
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2086S0127X
-----------------------------------------------------
Taxonomy Name | Trauma Surgery Physician
-----------------------------------------------------
License Number | MD49240
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------