Provider Demographics
NPI:1275586448
Name:WALLACE, RICHARD PETERKIN (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:PETERKIN
Last Name:WALLACE
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 1:1001 S FORT HARRISON AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-3905
Mailing Address - Country:US
Mailing Address - Phone:727-441-5044
Mailing Address - Fax:727-441-5008
Practice Address - Street 1:1001 S FORT HARRISON AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3941
Practice Address - Country:US
Practice Address - Phone:727-441-5044
Practice Address - Fax:727-441-5008
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85690207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00294408OtherRAILROAD MEDICARE NUMBER
FL270183900Medicaid
FLP00294408OtherRAILROAD MEDICARE NUMBER
H97959Medicare UPIN