Basic Information
Provider Information | |||||||||
NPI: | 1124225065 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WALLACE F. MARTIN, M.D. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 631 PROFESSIONAL DRIVE | ||||||||
Address2: | SUITE 300 | ||||||||
City: | LAWRENCEVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 300463371 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7709629977 | ||||||||
FaxNumber: | 7703399804 | ||||||||
Practice Location | |||||||||
Address1: | 631 PROFESSIONAL DR | ||||||||
Address2: | SUITE 300 | ||||||||
City: | LAWRENCEVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 300463371 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7709629977 | ||||||||
FaxNumber: | 7703399804 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/02/2007 | ||||||||
LastUpdateDate: | 09/01/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MARTIN | ||||||||
AuthorizedOfficialFirstName: | WALLACE | ||||||||
AuthorizedOfficialMiddleName: | FORD | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 7709629977 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 026153 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | GRP1797 | 01 | GA | MEDICARE GROUP# | OTHER | 00301914A | 05 | GA |   | MEDICAID |