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General NPI Number Information
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NPI Number | 1740220938
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Entity Type | Individual
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Provider Name | BARRETT JEFFREY WALLIS MD
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Gender | Male
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Dates
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Enumeration Date | 06/07/2006
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Last Update Date | 10/10/2024
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Provider Practice Location Address
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Address Line | 6152 W CORPORATE OAKS DR
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City | CRYSTAL RIVER
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State | FL
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Zip | 34429-8722
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Country | US
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Telephone | 352-564-3900
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Fax | 352-564-3906
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Provider Business Mailing Address
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Address Line | 835 SE 1ST CT
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City | CRYSTAL RIVER
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State | FL
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Zip | 34429-4612
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Country | US
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Telephone | 352-400-8000
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 35.088718
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | ME48685
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License Number State | FL
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