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General NPI Number Information
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NPI Number | 1821396151
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Entity Type | Individual
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Provider Name | ROBERT JENNINGS WALLACE MD
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Gender | Male
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Dates
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Enumeration Date | 03/10/2011
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Last Update Date | 07/24/2025
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Provider Practice Location Address
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Address Line | 3600 CENTRAL AVE
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City | ST PETERSBURG
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State | FL
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Zip | 33711-1345
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Country | US
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Telephone | 727-826-0700
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Fax | 727-954-6994
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Provider Business Mailing Address
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Address Line | 3600 CENTRAL AVE
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City | ST PETERSBURG
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State | FL
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Zip | 33711-1345
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Country | US
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Telephone | 727-826-0700
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Fax | 727-954-6994
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ME42522
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License Number State | FL
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