1962484634 NPI number — DR. GARY RHETT WALLACE M.D., FAAFP

Table of content: DR. GARY RHETT WALLACE M.D., FAAFP (NPI 1962484634)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962484634 NPI number — DR. GARY RHETT WALLACE M.D., FAAFP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
GARY
Provider Middle Name:
RHETT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D., FAAFP
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:
1962484634
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2817 REILLY RD
Provider Second Line Business Mailing Address:
WOMACK ARMY MEDICAL CENTER
Provider Business Mailing Address City Name:
FORT BRAGG
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28310-7324
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-907-8922
Provider Business Mailing Address Fax Number:
910-907-6069

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BLDG 5-4257
Provider Second Line Business Practice Location Address:
BASTOGNE EXTENSION
Provider Business Practice Location Address City Name:
FORT BRAGG
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28310-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-907-9560
Provider Business Practice Location Address Fax Number:
910-907-9818
Provider Enumeration Date:
11/17/2005

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: 207Q00000X , with the licence number:  J8821 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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