Provider Demographics
NPI:1447353784
Name:WALLACE, WILLIAM C (DO)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:C
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 JOHN PAUL JONES CIRCLE
Mailing Address - Street 2:NAVAL MEDICAL CENTER PORTSMOUTH
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23708
Mailing Address - Country:US
Mailing Address - Phone:757-953-7550
Mailing Address - Fax:
Practice Address - Street 1:620 JOHN PAUL JONES CIRCLE
Practice Address - Street 2:NAVAL MEDICAL CENTER PORTSMOUTH
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708
Practice Address - Country:US
Practice Address - Phone:757-953-7550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS009890L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine