Healthcare Provider Details

I. General information

NPI: 1689774390
Provider Name (Legal Business Name): WALLACE W MCLEAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2006
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 1ST AVE N
NAPLES FL
34102-6005
US

IV. Provider business mailing address

775 1ST AVE N
NAPLES FL
34102-6005
US

V. Phone/Fax

Practice location:
  • Phone: 239-262-3399
  • Fax: 239-261-1189
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME0025809
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberME0025809
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: