Provider Demographics
NPI:1518118462
Name:WALLACE, BRIAN ROBERT (DO)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:ROBERT
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3466 PINE RIDGE RD
Mailing Address - Street 2:STE A
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-3883
Mailing Address - Country:US
Mailing Address - Phone:239-261-2663
Mailing Address - Fax:236-262-5633
Practice Address - Street 1:1250 PINE RIDGE RD
Practice Address - Street 2:SUITE 203
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34108-8913
Practice Address - Country:US
Practice Address - Phone:236-261-2663
Practice Address - Fax:239-262-5633
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2019-06-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLOS12629207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH34.010952OtherMEDICAL LICENSE OH
FLOS12629OtherMEDICAL LICENSE FL