Healthcare Provider Details

I. General information

NPI: 1770228264
Provider Name (Legal Business Name): RYAN TODD WALLACE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2022
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 NW 17TH ST
MIAMI FL
33136-1134
US

IV. Provider business mailing address

3620 PONCE DE LEON BLVD
CORAL GABLES FL
33134-7356
US

V. Phone/Fax

Practice location:
  • Phone: 305-326-6000
  • Fax:
Mailing address:
  • Phone: 208-932-3234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME180519
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: