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NPI Code Detail

MEDICARE: DR. CHARLES DOUGLAS WALLACE M.D.

MEDICARE: DR. CHARLES DOUGLAS WALLACE M.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207X00000XOrthopaedic Surgery PhysicianG67953CA

General Provider Information

NPI Number : 1144229600
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. CHARLES DOUGLAS WALLACE M.D.
Provider Business Mailing Address
First Line : 3860 CALLE FORTUNADA
Second Line : STE #210
City : SAN DIEGO
State : CA
Zip : 92123-4802
Country : US
Telephone Number : 858-309-6303
Fax Number : 858-309-6301
Provider Business Practice Location Address
First Line : 3030 CHILDRENS WAY
Second Line : STE 410
City : SAN DIEGO
State : CA
Zip : 92123-4232
Country : US
Telephone Number : 858-966-6789
Fax Number : 858-966-8519
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/18/2005
Last Update Date : 11/02/2011

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