Provider Demographics
NPI:1437192531
Name:WALLACE, DANA V (MD)
Entity Type:Individual
Prefix:DR
First Name:DANA
Middle Name:V
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:11880 SW 40TH ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-3584
Mailing Address - Country:US
Mailing Address - Phone:305-223-8808
Mailing Address - Fax:305-223-8974
Practice Address - Street 1:2699 STIRLING RD STE B305
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-6546
Practice Address - Country:US
Practice Address - Phone:954-981-9180
Practice Address - Fax:954-961-4752
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0025502207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006256200Medicaid
FL93292XOtherMEDICARE
FL93292XOtherMEDICARE