Basic Information
| Provider Information | |||||||||
| NPI: | 1801337134 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204 N SILVER MAPLE DR | ||||||||
| Address2: | |||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704585483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5045542131 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5000 HENNESSY BLVD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708084375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257654050 | ||||||||
| FaxNumber: | 2257654046 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2017 | ||||||||
| LastUpdateDate: | 04/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 326195 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.