Individual
DR. KEVIN H WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1350 HICKORY ST, MELBOURNE, FL 32901-3224
(321) 434-4225
(321) 434-4247
Mailing address
3300 S FISKE BLVD, ROCKLEDGE, FL 32955-4306
Taxonomy
Speciality
Code
Description
License number
State
207RC0200X
Critical Care Medicine (Internal Medicine) Physician
ME81186
FL
207RP1001X
Pulmonary Disease Physician
Primary
ME81186
FL
207RS0012X
Sleep Medicine (Internal Medicine) Physician
ME81186
FL
208M00000X
Hospitalist Physician
ME81186
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
014488700
—
FL
Enumeration date
12/16/2005
Last updated
08/26/2022
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