Provider Demographics
NPI:1558772061
Name:PLANTE, WALLY (MD)
Entity Type:Individual
Prefix:
First Name:WALLY
Middle Name:
Last Name:PLANTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28420 BONITA CROSSINGS BLVD UNIT 110
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-3203
Mailing Address - Country:US
Mailing Address - Phone:239-235-0385
Mailing Address - Fax:239-237-5574
Practice Address - Street 1:28420 BONITA XING BLVD UNIT 110
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-3203
Practice Address - Country:US
Practice Address - Phone:239-235-0385
Practice Address - Fax:239-343-7008
Is Sole Proprietor?:No
Enumeration Date:2014-05-19
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1351292084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100164900Medicaid