Provider Demographics
NPI:1396185666
Name:WALLACE, AUDREY (MD)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 SE 17TH ST
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-4118
Mailing Address - Country:US
Mailing Address - Phone:352-732-0277
Mailing Address - Fax:
Practice Address - Street 1:2020 SE 17TH ST
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-4118
Practice Address - Country:US
Practice Address - Phone:352-732-0277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-01
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL336892085R0001X
390200000X
FLME1368002085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program