MEDICARE: DR. WALLACE ALVIN DONALDSON 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
1	208D00000X	General Practice Physician	MD00009019	WA

Other Identifiers

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

General Provider Information

NPI Number	:	1750355020
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WALLACE ALVIN DONALDSON M.D.

Provider Business Mailing Address
First Line	:	102 6TH ST
Second Line	:
City	:	ZILLAH
State	:	WA
Zip	:	98953-9442
Country	:	US
Telephone Number	:	509-829-5699
Fax Number	:	509-829-6366

Provider Business Practice Location Address
First Line	:	102 6TH ST
Second Line	:
City	:	ZILLAH
State	:	WA
Zip	:	98953-9442
Country	:	US
Telephone Number	:	509-829-5699
Fax Number	:	509-829-6366

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2006
Last Update Date	:	01/03/2012

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