Basic Information
| Provider Information | |||||||||
| NPI: | 1275725384 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 855 N WESTHAVEN DR | ||||||||
| Address2: | |||||||||
| City: | OSHKOSH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549047668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203038700 | ||||||||
| FaxNumber: | 9203038832 | ||||||||
| Practice Location | |||||||||
| Address1: | 855 N WESTHAVEN DR | ||||||||
| Address2: | |||||||||
| City: | OSHKOSH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549047668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203038700 | ||||||||
| FaxNumber: | 9203038832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2007 | ||||||||
| LastUpdateDate: | 12/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 1195 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | OS013436 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1195 | 01 | SC | MEDICAL LICENSE | OTHER | 60032-021 | 01 | WI | MEDICAL LICENSE | OTHER | OS013436 | 01 | PA | LICENSE | OTHER | 011953 | 05 | SC | MEDICAID |