Provider Demographics
NPI:1467509455
Name:WALLIS-CRESPO, MARIA (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:WALLIS-CRESPO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11645 DELWICK DR
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786
Mailing Address - Country:US
Mailing Address - Phone:407-258-8100
Mailing Address - Fax:
Practice Address - Street 1:6500 38TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1629
Practice Address - Country:US
Practice Address - Phone:727-341-4874
Practice Address - Fax:727-341-4925
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91778207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME91778OtherMEDICAL LICENSE