Provider Demographics
NPI:1740220938
Name:WALLIS, BARRETT JEFFREY (MD)
Entity Type:Individual
Prefix:
First Name:BARRETT
Middle Name:JEFFREY
Last Name:WALLIS
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:PO BOX 100707
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0707
Mailing Address - Country:US
Mailing Address - Phone:305-434-3400
Mailing Address - Fax:
Practice Address - Street 1:6152 W CORPORATE OAKS DR
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-8722
Practice Address - Country:US
Practice Address - Phone:352-564-3900
Practice Address - Fax:352-564-3906
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME48685207RG0100X
OH35.088718207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY12042524OtherMULTIPLAN
NY1299092OtherGHI GROUP HEALTH INC
FL146VVOtherBCBS OF FLORIDA
FL001690000Medicaid
FL333619OtherAVMED
D50520Medicare UPIN
FLCX829ZMedicare PIN