Provider Demographics
NPI:1306067954
Name:WALLACE, JAMES JEFFERSON III (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:JEFFERSON
Last Name:WALLACE
Suffix:III
Gender:M
Credentials:MD
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Mailing Address - Street 1:4143 COLUMBIA RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907
Mailing Address - Country:US
Mailing Address - Phone:706-651-1299
Mailing Address - Fax:706-651-1145
Practice Address - Street 1:4143 COLUMBIA RD
Practice Address - Street 2:SUITE D
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907
Practice Address - Country:US
Practice Address - Phone:706-651-1299
Practice Address - Fax:706-651-1145
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2024-06-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA0243692084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD46415Medicare UPIN