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General NPI Number Information
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NPI Number | 1922327485
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Entity Type | Individual
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Provider Name | HENRY C. WALLACE M.D.
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Gender | Male
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Dates
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Enumeration Date | 05/24/2010
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Last Update Date | 01/11/2019
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Provider Practice Location Address
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Address Line | 301 SOUTHRIDGE BLVD STE A
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City | HEBER SPRINGS
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State | AR
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Zip | 72543
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Country | US
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Telephone | 501-206-0176
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Fax | 501-206-0179
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Provider Business Mailing Address
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Address Line | 800 FAIR PARK BLVD
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City | LITTLE ROCK
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State | AR
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Zip | 72204-1720
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Country | US
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Telephone | 501-604-6900
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Fax |
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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 | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | N4831
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License Number State | TX
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