Provider Demographics
NPI:1851470033
Name:WALLACE, DOUGLAS CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:CHARLES
Last Name:WALLACE
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 1:3900 ST FRANCIS WAY
Mailing Address - Street 2:STE 201
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4923
Mailing Address - Country:US
Mailing Address - Phone:765-446-7981
Mailing Address - Fax:765-446-7982
Practice Address - Street 1:3900 ST FRANCIS WAY
Practice Address - Street 2:STE 201
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4923
Practice Address - Country:US
Practice Address - Phone:765-446-7981
Practice Address - Fax:765-446-7982
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66727208G00000X
IL036-101410208G00000X
IN01071946A208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036112410Medicaid
IL256510001Medicare PIN