Provider Demographics
NPI:1821396151
Name:WALLACE, ROBERT JENNINGS (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JENNINGS
Last Name:WALLACE
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 1:3600 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33711-1345
Mailing Address - Country:US
Mailing Address - Phone:727-826-0700
Mailing Address - Fax:727-954-6994
Practice Address - Street 1:3600 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33711-1345
Practice Address - Country:US
Practice Address - Phone:727-826-0700
Practice Address - Fax:727-954-6994
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-10
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 42522207QA0505X
FLME42522207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1108108OtherSTAYWELL
0007618489OtherAETNA
FL14NU6OtherFLORIDA BLUE
FL11382461OtherCAQH
189052OtherCIGNA
000121140OtherUNITED INSURANCE
05595987OtherCLEAR
14NU6OtherFLORIDA BLUE
FL111163300Medicaid
FL14NU6OtherBLUE CROSS BLUE SHIELD