Basic Information
| Provider Information | |||||||||
| NPI: | 1629089156 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2108 | ||||||||
| Address2: | |||||||||
| City: | ROCKWALL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750875008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724631253 | ||||||||
| FaxNumber: | 9724630758 | ||||||||
| Practice Location | |||||||||
| Address1: | 6800 HERITAGE PKWY STE 102 | ||||||||
| Address2: | |||||||||
| City: | ROCKWALL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750878746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724631253 | ||||||||
| FaxNumber: | 2146071641 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 01/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | J3932 | TX | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.