1144229600 NPI number — DR. CHARLES DOUGLAS WALLACE M.D.

Table of content: DR. CHARLES DOUGLAS WALLACE M.D. (NPI 1144229600)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144229600 NPI number — DR. CHARLES DOUGLAS WALLACE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
CHARLES
Provider Middle Name:
DOUGLAS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144229600
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3860 CALLE FORTUNADA
Provider Second Line Business Mailing Address:
STE #210
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92123-4802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-309-6303
Provider Business Mailing Address Fax Number:
858-309-6301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3030 CHILDRENS WAY
Provider Second Line Business Practice Location Address:
STE 410
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92123-4232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-966-6789
Provider Business Practice Location Address Fax Number:
858-966-8519
Provider Enumeration Date:
07/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  G67953 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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