Provider Demographics
NPI:1376748269
Name:COMBS, WALLACE E (MD)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:E
Last Name:COMBS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5325 WOODHAVEN LN
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2657
Mailing Address - Country:US
Mailing Address - Phone:863-619-5623
Mailing Address - Fax:863-619-5623
Practice Address - Street 1:5325 WOODHAVEN LN
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2657
Practice Address - Country:US
Practice Address - Phone:863-619-5623
Practice Address - Fax:863-619-5623
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY130572084P0804X
FLME 109092084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD56622Medicare UPIN