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NPI Code Detail

MEDICARE: CHARLES ALAN WALLACE MD

MEDICARE: CHARLES ALAN WALLACE MD
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
12086S0122XPlastic and Reconstructive Surgery PhysicianG3885TX

General Provider Information

NPI Number : 1164422481
Entity Type Code : Individual
Provider Name (Legal Business Name) : CHARLES ALAN WALLACE MD
Provider Business Mailing Address
First Line : 17110 DALLAS PKWY
Second Line : SUITE 100
City : DALLAS
State : TX
Zip : 75248-1167
Country : US
Telephone Number : 972-380-7090
Fax Number : 972-380-7016
Provider Business Practice Location Address
First Line : 17110 DALLAS PKWY
Second Line : SUITE 100
City : DALLAS
State : TX
Zip : 75248-1167
Country : US
Telephone Number : 972-380-7090
Fax Number : 972-380-7016
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/28/2005
Last Update Date : 07/14/2010

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Directions to “ CHARLES ALAN WALLACE MD” Practice Location

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