Healthcare Provider Details

I. General information

NPI: 1306875869
Provider Name (Legal Business Name): PAUL R. WALLACE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 S HIGHLAND AVE
CLEARWATER FL
33756-4446
US

IV. Provider business mailing address

1301 2ND AVE SW
LARGO FL
33770-3120
US

V. Phone/Fax

Practice location:
  • Phone: 727-219-1833
  • Fax: 727-330-2908
Mailing address:
  • Phone: 727-584-7706
  • Fax: 727-581-3727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME69904
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: