Individual
DR. KENNETH A WALLACE III
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1091 SE 59TH ST, OCALA, FL 34480-6146
(850) 597-0324
Mailing address
1091 SE 59TH ST, OCALA, FL 34480-6146
(850) 597-0324
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
ME73625
FL
207ND0101X
MOHS-Micrographic Surgery Physician
Primary
ME73625
FL
207NS0135X
Procedural Dermatology Physician
ME73625
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000651600
—
FL
Enumeration date
04/25/2006
Last updated
04/02/2020
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