Healthcare Provider Details

I. General information

NPI: 1770537649
Provider Name (Legal Business Name): ELAINE WALLACE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 09/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 S UNIVERSITY DR #4316
DAVIE FL
33328-2018
US

IV. Provider business mailing address

3001 W ROLLING HILLS CIR 1-408
DAVIE FL
33328-1948
US

V. Phone/Fax

Practice location:
  • Phone: 954-262-4316
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberOS8356
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: