Wallace Jackson Champlain, DO

Primary specialty

Obstetrics & Gynecology PhysicianTaxonomy code 207V00000X

License

1994 Issued in OK

Practice address

1500 E Downing St Ste 208
Tahlequah, OK 74464-3234

Phone

(918) 456-2496

Fax

(918) 456-7108

NPI assigned

Feb 15, 2006

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in OK

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Osteopathy

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Northeastern Oklahoma Community Health Centers Inc

  • Federally Qualified Health Center (FQHC)
  • Hulbert, OK
  • NPI 1518070481
  Medicare reassignment NPD
• Northeastern Oklahoma Community Health Centers Inc

  • Federally Qualified Health Center (FQHC)
  • Pryor, OK
  • NPI 1669101184
  NPD

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

{
    "created_epoch": "1139961600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1559606400000",
    "number": "1689648636",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1500 E DOWNING SUITE 208",
            "city": "TAHLEQUAH",
            "state": "OK",
            "postal_code": "744643363",
            "telephone_number": "918-456-2496",
            "fax_number": "918-456-7108"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1500 E DOWNING ST STE 208",
            "city": "TAHLEQUAH",
            "state": "OK",
            "postal_code": "744643234",
            "telephone_number": "918-456-2496",
            "fax_number": "918-456-7108"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "127 E Main",
            "address_purpose": "LOCATION",
            "city": "Hulbert",
            "state": "OK",
            "postal_code": "74441",
            "country_code": "US",
            "telephone_number": "918-772-3390",
            "fax_number": "918-772-3638",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "CHAMPLAIN",
        "first_name": "WALLACE",
        "middle_name": "JACKSON",
        "credential": "DO",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-02-15",
        "last_updated": "2019-06-04",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207V00000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology",
            "state": "OK",
            "license": "1994",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100118860A",
            "state": "OK"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Richard Castillo, DO
• Ronald Castor II
• Charlene Marie Catterlin, PHARM. D.
• Dana Michelle Caviness, APRN-CNP
• Kimberley Chaffin
• Laura Lai Ming Chan, OD
• Elizabeth Lou Chanate
• Anna Grace Chandler
• James Michael Chapple, PHARM D
• Steven Albert Chase, OT/L

• Obstetrics & Gynecology Physician in Tahlequah, OK
• Providers in Tahlequah, OK by specialty
• Obstetrics & Gynecology Physician in Oklahoma

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 4, 2019; 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.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.