MEDICARE: DR. SUEMOY S WALLACE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	49311	AZ
2	2086S0102X	Surgical Critical Care Physician	49311	AZ
3	208600000X	Surgery Physician	49311	AZ
4	202K00000X	Phlebology Physician	49311	AZ
5	2086S0127X	Trauma Surgery Physician	49311	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184850885
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUEMOY S WALLACE M.D.

Provider Business Mailing Address
First Line	:	3820 NORTHDALE BLVD STE 201
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33624-1893
Country	:	US
Telephone Number	:	800-991-6117
Fax Number	:	800-812-8191

Provider Business Practice Location Address
First Line	:	1010 E MCDOWELL RD STE 103
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85006-2607
Country	:	US
Telephone Number	:	800-991-6117
Fax Number	:	888-812-8191

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2009
Last Update Date	:	03/16/2026

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Directions to “ DR. SUEMOY S WALLACE M.D.” Practice Location

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