Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RR0500X | Rheumatology | G24760 | CA |
NPI | 1043252919 |
---|---|
Provider Name | Dr. James Davis Wallace |
First Address | Long Beach, CA 90806-2710 |
Second Address | Long Beach, CA 90806-2710 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/06/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A42376 | (02) | CA |