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Individual
ROBERT VERNON WALLACE
Active
Individual
ROBERT VERNON WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M. D.
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
ME0013849
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
36161
BLUE CROSS BLUE SHIELD
FL
01
—
622647
AETNA
FL
01
—
ME0013849
PROFESSIONAL LICENSE
FL
Enumeration date
08/20/2006
Last updated
03/07/2023
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