Active NPI
James Jefferson Wallace III, MD
- Psychiatry Physician
- Martinez, GA
National Provider Identifier
1306067954
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychiatry Physician
- License
- 024369
- Practice address
- 4143 Columbia Rd
Suite D
Martinez, GA 30907 - Phone
- (706) 651-1299
- Fax
- (706) 651-1145
- NPI assigned
- May 1, 2007
- Last updated
- Jun 12, 2024
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychiatry Physician | 2084P0800X | 024369 | GA | Primary |
Addresses
Primary practice location
4143 Columbia Rd
Suite D
Martinez, GA 30907
Mailing address
4143 Columbia Rd
Suite D
Martinez, GA 30907
Phone (706) 651-1299
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
- Opted out of Medicare
- Yes, effective Jan 29, 2021 through Jan 29, 2027
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 024369 | GA | MD | Psychiatry Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1177977600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1718150400000",
"number": "1306067954",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4143 COLUMBIA RD",
"address_2": "SUITE D",
"city": "MARTINEZ",
"state": "GA",
"postal_code": "30907",
"telephone_number": "706-651-1299",
"fax_number": "706-651-1145"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4143 COLUMBIA RD",
"address_2": "SUITE D",
"city": "MARTINEZ",
"state": "GA",
"postal_code": "30907",
"telephone_number": "706-651-1299",
"fax_number": "706-651-1145"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "JAMES",
"middle_name": "JEFFERSON",
"name_suffix": "III",
"credential": "MD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2007-05-01",
"last_updated": "2024-06-12",
"certification_date": "2024-06-12",
"status": "A"
},
"taxonomies": [
{
"code": "2084P0800X",
"taxonomy_group": "",
"desc": "Psychiatry & Neurology, Psychiatry",
"state": "GA",
"license": "024369",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Martinez, GA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 12, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.