Provider Demographics
NPI:1215139381
Name:WALLACE, LYDIA VALLADARES (DO)
Entity type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:VALLADARES
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 1:131 S CITRUS AVE
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34452-4701
Mailing Address - Country:US
Mailing Address - Phone:352-344-6930
Mailing Address - Fax:352-344-4955
Practice Address - Street 1:131 S CITRUS AVE
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34452-4701
Practice Address - Country:US
Practice Address - Phone:352-344-6930
Practice Address - Fax:352-344-4955
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 10688207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001933100Medicaid
FL006676100Medicaid
FLBJ846Medicare PIN
FL001933100Medicaid