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General NPI Number Information
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NPI Number | 1780652792
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Entity Type | Individual
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Provider Name | CHARLES W WALLACE MD
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Gender | Male
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Dates
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Enumeration Date | 03/08/2006
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Last Update Date | 01/14/2025
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Provider Practice Location Address
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Address Line | 4455 DRESSLER RD NW
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City | CANTON
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State | OH
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Zip | 44718-2785
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Country | US
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Telephone | 330-497-6555
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Fax | 330-497-3281
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Provider Business Mailing Address
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Address Line | 4455 DRESSLER RD NW
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City | CANTON
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State | OH
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Zip | 44718-2785
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Country | US
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Telephone | 330-497-6555
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Fax | 330-497-3281
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 35080468W
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 70831
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License Number State | MN
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 330155
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License Number State | LA
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