John Wallace II, MD

Primary specialty

Psychiatry PhysicianTaxonomy code 2084P0800X

License

98-01546 Issued in NC

Practice address

1705 Gardner Dr
Wilmington, NC 28405-8873

Phone

(910) 343-5300

Fax

(910) 254-1352

NPI assigned

Apr 28, 2008

Sex

Male

Sole proprietor

No

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

Specialties & licenses 2

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

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

{
    "created_epoch": "1209340800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1430092800000",
    "number": "1457526808",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1705 GARDNER DR",
            "city": "WILMINGTON",
            "state": "NC",
            "postal_code": "284058873",
            "telephone_number": "910-343-5300",
            "fax_number": "910-254-1352"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1705 GARDNER DR",
            "city": "WILMINGTON",
            "state": "NC",
            "postal_code": "284058873",
            "telephone_number": "910-343-5300",
            "fax_number": "910-254-1352"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "JOHN",
        "name_suffix": "II",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2008-04-28",
        "last_updated": "2015-04-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "NC",
            "license": "9801546",
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "NC",
            "license": "98-01546",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5920117",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Benjamin Evans Wall, MD
• Callan E Wall, RD, LDN
• Renee V. Wall, PA-C
• Brooke Elizabeth Wallace, OTR/L
• Emma B. Wallace, LMFT
• Leshonda Tequilla Wallace, FNP
• Morgan Eaton Wallace
• Stephen Curtis Wallace, D.D.S.,M.H.S.,P.A.
• Christina Clair Waller, LCSW
• Allan Todd Walls, DDS

• Psychiatry Physician in Wilmington, NC
• Providers in Wilmington, NC by specialty
• Psychiatry Physician in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 27, 2015; 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.