Provider Demographics
NPI:1437257532
Name:COMBS, WALLACE MASON II (MD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:MASON
Last Name:COMBS
Suffix:II
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 1:120 PINNACLES DR STE 1
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-2322
Mailing Address - Country:US
Mailing Address - Phone:386-586-6611
Mailing Address - Fax:386-586-6633
Practice Address - Street 1:61 MEMORIAL MEDICAL PARKWAY
Practice Address - Street 2:SUITE 3811
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164
Practice Address - Country:US
Practice Address - Phone:386-586-6611
Practice Address - Fax:386-586-6633
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME55590207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
K3901Medicare ID - Type Unspecified
F53344Medicare UPIN