DOUGLAS CHARLES WALLACE MD Medical Doctor License verification

Business Entity

NOT RENEWED

License Type

Medical Doctor

Description

LICENSED PHYSICIAN CONTROLLED SUBSTANCE

License Number

33*****73

License Status

NOT RENEWED

Business

First Name

DOUGLAS

Middle

CHARLES

Last Name

WALLACE

Suffix

Business Name

DOUGLAS CHARLES WALLACE MD

Original Issue Date

09/22/2004

Effective Date

09/22/2004

Expiration Date

07/31/2005

City

MOLINE

State

Zip

61265

County

ROCK ISLAND

Controlled Substance Schedule

II III IV V

Ever Disciplined

LastModifiedDate

04/07/2011