Healthcare Provider Details

I. General information

NPI: 1821396151
Provider Name (Legal Business Name): ROBERT JENNINGS WALLACE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2011
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 CENTRAL AVE
ST PETERSBURG FL
33711-1345
US

IV. Provider business mailing address

3600 CENTRAL AVE
ST PETERSBURG FL
33711-1345
US

V. Phone/Fax

Practice location:
  • Phone: 727-826-0700
  • Fax: 727-954-6994
Mailing address:
  • Phone: 727-826-0700
  • Fax: 727-954-6994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME42522
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: