Douglas Charles Wallace, M.D.

Primary specialty

Thoracic Surgery (Cardiothoracic Vascular Surgery) PhysicianTaxonomy code 208G00000X

License

01071946A Issued in IN

Practice address

3900 St Francis Way
Ste 201
Lafayette, IN 47905-4923

Phone

(765) 446-7981

Fax

(765) 446-7982

NPI assigned

Nov 6, 2006

Sex

Male

Sole proprietor

No

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

Specialties & licenses 3

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

Practice roles

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.

• Memorial Management Inc

  • Durable Medical Equipment & Medical Supplies
  • Marion, IL
  • NPI 1518423904
  NPD (past)
• Memorial Management Inc

  • Family Medicine Physician
  • Marion, IL
  • NPI 1720087950
  NPD (past)

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

{
    "created_epoch": "1162771200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1355875200000",
    "number": "1851470033",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3900 ST FRANCIS WAY",
            "address_2": "STE 201",
            "city": "LAFAYETTE",
            "state": "IN",
            "postal_code": "479054923",
            "telephone_number": "765-446-7981",
            "fax_number": "765-446-7982"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3900 ST FRANCIS WAY",
            "address_2": "STE 201",
            "city": "LAFAYETTE",
            "state": "IN",
            "postal_code": "479054923",
            "telephone_number": "765-446-7981",
            "fax_number": "765-446-7982"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "DOUGLAS",
        "middle_name": "CHARLES",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-11-06",
        "last_updated": "2012-12-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208G00000X",
            "taxonomy_group": "",
            "desc": "Thoracic Surgery (Cardiothoracic Vascular Surgery)",
            "state": "CA",
            "license": "G66727",
            "primary": false
        },
        {
            "code": "208G00000X",
            "taxonomy_group": "",
            "desc": "Thoracic Surgery (Cardiothoracic Vascular Surgery)",
            "state": "IL",
            "license": "036-101410",
            "primary": false
        },
        {
            "code": "208G00000X",
            "taxonomy_group": "",
            "desc": "Thoracic Surgery (Cardiothoracic Vascular Surgery)",
            "state": "IN",
            "license": "01071946A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036112410",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Walgreens
• Candice Gay Walker, CRNP
• Katarina M Walker, MS, RD
• Lateesha T Walker
• Autumn Wall, LCSW
• Elizabeth Lee Wallace
• Noel Wallace, M.D.
• Christine Diane Waller, DO
• Emily Hope Walsh, PA-C
• Erin Walter, CST

• Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician in Lafayette, IN
• Providers in Lafayette, IN by specialty
• Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 19, 2012; 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.