Healthcare Provider Details

I. General information

NPI: 1245602069
Provider Name (Legal Business Name): FLEMING ISLAND PLASTIC SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2015
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 EAGLE HARBOR PKWY STE B
FLEMING ISLAND FL
32003-4324
US

IV. Provider business mailing address

916 ALAMEDA LN
SAINT JOHNS FL
32259-6903
US

V. Phone/Fax

Practice location:
  • Phone: 904-990-3477
  • Fax: 904-621-9272
Mailing address:
  • Phone: 904-348-0727
  • Fax: 904-621-9272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberME107749
License Number StateFL

VIII. Authorized Official

Name: DR. WILLIAM WALLACE
Title or Position: MANAGER/OWNER
Credential: MD
Phone: 904-990-3477