Gregory Stephen Wallace, MD

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

051099 Issued in GA

Practice address

1042 Mason Woods Dr NE
Atlanta, GA 30329-3802

Phone

(678) 974-7424

NPI assigned

Dec 5, 2018

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Doctor of Medicine

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1543968000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1543968000000",
    "number": "1265902092",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1042 MASON WOODS DR NE",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303293802",
            "telephone_number": "678-974-7424"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1042 MASON WOODS DR NE",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303293802",
            "telephone_number": "678-974-7424"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "GREGORY",
        "middle_name": "STEPHEN",
        "credential": "MD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2018-12-05",
        "last_updated": "2018-12-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "CA",
            "license": "G81645",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "GA",
            "license": "051099",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Chasity Wallace
• Colby Evan Wallace, D.P.T.
• Constance Wallace, M.S., LPC
• Felecia Zanetta Wallace, LMT, CMT
• Grant Wallace
• Guy Wallace
• Jaclyn Renee Wallace, NNP-BC
• Jacqueline Wallace
• Jeffrey Robert Wallace, D.D.S
• Jennifer Wallace, MS, CCC-SLP

• Family Medicine Physician in Atlanta, GA
• Providers in Atlanta, GA by specialty
• Family Medicine Physician in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 5, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.