Individual
DR. RICHARD B WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
215 N 3RD ST, LEESBURG, FL 34748-5105
(352) 315-7900
(352) 315-7587
Mailing address
215 N 3RD ST, LEESBURG, FL 34748-5105
(352) 315-7900
(352) 315-7587
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
Primary
05-22572
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
052290
BCBS
KS
05
—
100098100A
—
KS
Enumeration date
09/27/2006
Last updated
04/30/2019
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