Provider Demographics
NPI:1063559417
Name:WALLACE, ARLIE N (DO)
Entity type:Individual
Prefix:
First Name:ARLIE
Middle Name:N
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S TAMIAMI TRL
Mailing Address - Street 2:SUITE 5
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-5100
Mailing Address - Country:US
Mailing Address - Phone:941-366-0664
Mailing Address - Fax:
Practice Address - Street 1:3300 S TAMIAMI TRL
Practice Address - Street 2:SUITE 5
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-5100
Practice Address - Country:US
Practice Address - Phone:941-366-0664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS-00047912084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry