Provider Demographics
NPI:1023004207
Name:WALLIS, JOHN BRENT (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BRENT
Last Name:WALLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 PARK CENTRE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5373
Mailing Address - Country:US
Mailing Address - Phone:504-454-9020
Mailing Address - Fax:504-454-9031
Practice Address - Street 1:4710 S CARROLLTON AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119
Practice Address - Country:US
Practice Address - Phone:504-454-9020
Practice Address - Fax:504-454-9031
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA025100207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1422355Medicaid
LA4J117F669Medicare PIN
LA4J117Medicare PIN
LAI19059Medicare UPIN