Provider Demographics
NPI:1922113174
Name:WALLACE, ROBERT VERNON (M D)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:VERNON
Last Name:WALLACE
Suffix:
Gender:M
Credentials:M D
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 848
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33970-0848
Mailing Address - Country:US
Mailing Address - Phone:239-369-2903
Mailing Address - Fax:239-369-0500
Practice Address - Street 1:400 LEE BLVD
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-4923
Practice Address - Country:US
Practice Address - Phone:239-369-2903
Practice Address - Fax:239-369-0500
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0013849207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL36161OtherBLUE CROSS BLUE SHIELD
FL622647OtherAETNA
FLME0013849OtherPROFESSIONAL LICENSE
FLME0013849OtherPROFESSIONAL LICENSE
FLAW4904555OtherDEA
FL36161Medicare ID - Type UnspecifiedMEDICARE ID