Provider Demographics
NPI:1831490432
Name:THOMAS, WALLACE (MD)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:
Last Name:THOMAS
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 1:2784 SW 129TH TER
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-3852
Mailing Address - Country:US
Mailing Address - Phone:561-201-3234
Mailing Address - Fax:
Practice Address - Street 1:300 EXECUTIVE CENTER DR
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-4842
Practice Address - Country:US
Practice Address - Phone:561-201-3234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-12
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME126338207R00000X, 208M00000X
ALME126338208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018564000Medicaid