Provider Demographics
NPI:1972558542
Name:WEATHERLY, WALLACE W (MD)
Entity type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:W
Last Name:WEATHERLY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:907 E SUNFLOWER RD
Mailing Address - Street 2:STE 102
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-2830
Mailing Address - Country:US
Mailing Address - Phone:662-843-8885
Mailing Address - Fax:662-843-2280
Practice Address - Street 1:1801 CRANE RIDGE DR
Practice Address - Street 2:SUITE C
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4902
Practice Address - Country:US
Practice Address - Phone:601-981-5633
Practice Address - Fax:601-981-1844
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2017-12-19
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Provider Licenses
StateLicense IDTaxonomies
MS11796207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSE95980Medicare UPIN
MS200000469Medicare ID - Type Unspecified