Provider Demographics
NPI:1457442477
Name:WALLACE, RICHARD B (DO)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:B
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5105
Mailing Address - Country:US
Mailing Address - Phone:352-315-7900
Mailing Address - Fax:352-315-7587
Practice Address - Street 1:215 N 3RD ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5105
Practice Address - Country:US
Practice Address - Phone:352-315-7900
Practice Address - Fax:352-315-7587
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL05-225722084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100098100AMedicaid
KS052290OtherBCBS
KSF24247Medicare UPIN
KS052290Medicare ID - Type UnspecifiedMEDICARE
KS100098100AMedicaid