Healthcare Provider Details

I. General information

NPI: 1437192531
Provider Name (Legal Business Name): DANA V WALLACE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2699 STIRLING RD STE B305
FT LAUDERDALE FL
33312-6546
US

IV. Provider business mailing address

11880 SW 40TH ST SUITE 304
MIAMI FL
33175-3584
US

V. Phone/Fax

Practice location:
  • Phone: 954-981-9180
  • Fax: 954-961-4752
Mailing address:
  • Phone: 305-223-8808
  • Fax: 305-223-8974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberME0025502
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: