Individual
BRIAN ROBERT WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
1250 PINE RIDGE RD, SUITE 203, NAPLES, FL 34108-8913
(236) 261-2663
(239) 262-5633
Mailing address
3466 PINE RIDGE RD, STE A, NAPLES, FL 34109-3883
(239) 261-2663
(236) 262-5633
Taxonomy
Speciality
Code
Description
License number
State
207XX0005X
Sports Medicine (Orthopaedic Surgery) Physician
Primary
OS12629
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
34.010952
MEDICAL LICENSE OH
OH
01
—
OS12629
MEDICAL LICENSE FL
FL
Enumeration date
10/08/2008
Last updated
06/24/2019
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