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NPI Code Detail

MEDICARE: TRACY WALLACE MD

MEDICARE: TRACY 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
1208000000XPediatrics Physician204717LA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1720306558
Entity Type Code : Individual
Provider Name (Legal Business Name) : TRACY WALLACE MD
Provider Business Mailing Address
First Line : 5959 S SHERWOOD FOREST BLVD
Second Line :
City : BATON ROUGE
State : LA
Zip : 70816-6038
Country : US
Telephone Number : 225-765-5727
Fax Number : 225-765-9196
Provider Business Practice Location Address
First Line : 1937 S BURNSIDE AVE
Second Line :
City : GONZALES
State : LA
Zip : 70737-4632
Country : US
Telephone Number : 225-765-5500
Fax Number : 225-644-9286
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/04/2010
Last Update Date : 05/19/2021

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Directions to “ TRACY WALLACE MD” Practice Location

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