Wallace, John T
Wallace, John T is an individual health care provider with primary practice located at 205 South St , Fort Bragg CA 95437-5540. He recently has only one registered license in Allopathic & Osteopathic Physicians / Internal Medicine, which is considered as his primary health care specialty. Wallace, John T can be contacted via phone (707) 964-1251.Contact Information
Primary practice address
205 South St
Fort Bragg CA 95437-5540
Phone: (707) 964-1251
Fax: (707) 961-2722
Website:
Health care specialties
| Specialty | Code | License # | State |
|---|---|---|---|
| Allopathic & Osteopathic Physicians / Internal Medicine | 207R00000X | G37773 | California |
Profile Details
| NPI number | 1023079803 |
|---|---|
| LBN Legal business name | Wallace, John T |
| Credentials | Doctor of Medicine (MD) |
| Entity | Individual |
| Sole proprietor 1 | No |
| Enumeration date | Mar 31st, 2006 |
| Last updated | Dec 22nd, 2011 - about 13 years ago |
1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.
Identifiers
| State | Type | Number | Issuer |
|---|---|---|---|
| All States | NPI | 1023079803 | NPPES |
| California | MEDICAID | 00G377730 |
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