Provider Demographics
NPI:1386648228
Name:WALLIS, TED W (MD)
Entity type:Individual
Prefix:DR
First Name:TED
Middle Name:W
Last Name:WALLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 WALLIS DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-4637
Mailing Address - Country:US
Mailing Address - Phone:512-329-9459
Mailing Address - Fax:
Practice Address - Street 1:4007 JAMES CASEY ST STE B200
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1181
Practice Address - Country:US
Practice Address - Phone:512-441-9799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6677174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist