Healthcare Provider Details

I. General information

NPI: 1033195631
Provider Name (Legal Business Name): KEVIN H WALLACE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 HICKORY ST
MELBOURNE FL
32901-3224
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-4225
  • Fax: 321-434-4247
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberME81186
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberME81186
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME81186
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberME81186
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: