Basic Information
| Provider Information | |||||||||
| NPI: | 1225026206 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | ARTHUR | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1515 N HARVARD AVE | ||||||||
| Address2: | STE E | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741154957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188326049 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1717 S UTICA AVE STE A | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741045346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187487557 | ||||||||
| FaxNumber: | 9187487514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 04/13/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 1864 | OK | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 100228470B | 05 | OK | MEDICAID |