Provider Demographics
NPI:1851327332
Name:PHILIPS, WALLACE M JR (MD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:M
Last Name:PHILIPS
Suffix:JR
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:1255 CORPORATE DR
Mailing Address - Street 2:THIRD FLOOR
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-2518
Mailing Address - Country:US
Mailing Address - Phone:972-791-1224
Mailing Address - Fax:877-594-5434
Practice Address - Street 1:1021 E ROBINSON ST
Practice Address - Street 2:SUITE C
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32801-2004
Practice Address - Country:US
Practice Address - Phone:407-841-4022
Practice Address - Fax:407-839-5074
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-24
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME14099207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21111Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
FLD51209Medicare UPIN
FL05259XMedicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NUMBE