Provider Demographics
NPI:1346269883
Name:WALLACE, MERVIN P (MD)
Entity Type:Individual
Prefix:
First Name:MERVIN
Middle Name:P
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:PO BOX 12427
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32317-2427
Mailing Address - Country:US
Mailing Address - Phone:850-297-0114
Mailing Address - Fax:850-297-2020
Practice Address - Street 1:1803 MICCOSUKEE COMMONS DR
Practice Address - Street 2:SUITE 202
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-7403
Practice Address - Country:US
Practice Address - Phone:850-402-6205
Practice Address - Fax:850-325-6017
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME95779207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL276781300Medicaid
FLCN3432OtherGROUP MEDICARE RR
FLP00964768OtherMEDICARE RR
FLCN3432OtherGROUP MEDICARE RR
FLU8235TMedicare PIN