Provider Demographics
NPI:1154946606
Name:WALLACE, CATHERINE (MD)
Entity type:Individual
Prefix:
First Name:CATHERINE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 MERCHANTS DR STE A
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-4749
Mailing Address - Country:US
Mailing Address - Phone:404-543-4506
Mailing Address - Fax:
Practice Address - Street 1:243 MERCHANTS DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30132-4700
Practice Address - Country:US
Practice Address - Phone:770-230-9967
Practice Address - Fax:770-445-5860
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA94669208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA8101560001OtherDME MAC JURISDICTION C