Provider Demographics
NPI:1093020505
Name:GEORGE, WALES THOTTATHIKUNNATH (MD)
Entity type:Individual
Prefix:
First Name:WALES
Middle Name:THOTTATHIKUNNATH
Last Name:GEORGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:WALES
Other - Middle Name:
Other - Last Name:THOTTATHIKUNNATH GEORGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:382 TAYLOR DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-4023
Mailing Address - Country:US
Mailing Address - Phone:602-568-9067
Mailing Address - Fax:
Practice Address - Street 1:382 TAYLOR DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-4023
Practice Address - Country:US
Practice Address - Phone:434-799-3220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014009562084P0800X
VA01012565762084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry