Provider Demographics
NPI:1295791754
Name:WALLACE, KENNETH A III (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:WALLACE
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KENNETH
Other - Middle Name:A
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1091 SE 59TH ST
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34480-6146
Mailing Address - Country:US
Mailing Address - Phone:850-597-0324
Mailing Address - Fax:
Practice Address - Street 1:1091 SE 59TH ST
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34480-6146
Practice Address - Country:US
Practice Address - Phone:850-597-0324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73625207N00000X, 207NS0135X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000651600Medicaid
FL000651600Medicaid
FL000651600Medicaid
FL42692XMedicare PIN