Provider Demographics
NPI:1306875869
Name:WALLACE, PAUL R (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:R
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1301 2ND AVE SW
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-3120
Mailing Address - Country:US
Mailing Address - Phone:727-584-7706
Mailing Address - Fax:727-581-3727
Practice Address - Street 1:855 S HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-4446
Practice Address - Country:US
Practice Address - Phone:727-219-1833
Practice Address - Fax:727-330-2908
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME69904207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
28941Medicare ID - Type Unspecified
G27301Medicare UPIN