Provider Demographics
NPI:1144596974
Name:WALLEN, JARED JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:JOHN
Last Name:WALLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:938 OAKFIELD DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4950
Mailing Address - Country:US
Mailing Address - Phone:813-278-8850
Mailing Address - Fax:813-820-3508
Practice Address - Street 1:938 OAKFIELD DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4950
Practice Address - Country:US
Practice Address - Phone:813-278-8850
Practice Address - Fax:813-820-3508
Is Sole Proprietor?:No
Enumeration Date:2012-03-27
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME131777208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL120075300Medicaid