Provider Demographics
NPI:1831490432
Name:THOMAS, WALLACE (MD)
Entity type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10936 NW 41ST DR
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-7762
Mailing Address - Country:US
Mailing Address - Phone:561-201-3234
Mailing Address - Fax:320-238-7353
Practice Address - Street 1:305 MEMORIAL MEDICAL PKWY STE 307
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5169
Practice Address - Country:US
Practice Address - Phone:386-231-4351
Practice Address - Fax:386-231-3517
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-12
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308521207R00000X
FLME126338207R00000X, 208M00000X, 207RP1001X
ALME126338208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018564000Medicaid