Richard B Wallace, D.O.

Primary specialty

Psychiatry PhysicianTaxonomy code 2084P0800X

License

05-22572 Issued in FL

Practice address

215 N 3Rd St
Leesburg, FL 34748-5105

Phone

(352) 315-7900

Fax

(352) 315-7587

NPI assigned

Sep 27, 2006

Last updated

Apr 30, 2019By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Osteopathy

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Counseling and Mediation Center, Inc.

  • Professional Counselor
  • Dodge City, KS
  • NPI 1932585577
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1159315200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1556582400000",
    "number": "1457442477",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "215 N 3RD ST",
            "city": "LEESBURG",
            "state": "FL",
            "postal_code": "347485105",
            "telephone_number": "352-315-7900",
            "fax_number": "352-315-7587"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "215 N 3RD ST",
            "city": "LEESBURG",
            "state": "FL",
            "postal_code": "347485105",
            "telephone_number": "352-315-7900",
            "fax_number": "352-315-7587"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "RICHARD",
        "middle_name": "B",
        "name_prefix": "Dr.",
        "credential": "D.O.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-09-27",
        "last_updated": "2019-04-30",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "FL",
            "license": "05-22572",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100098100A",
            "state": "KS"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "052290",
            "state": "KS"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Walgreen Co (Walgreens #06940)
• Walgreen Co (Walgreens #06887)
• Edgar Alfred Walker Jr., M.D.
• Jercoby Demin Walker
• Kevin Bruce Wallace, D.M.D.
• Lindsey Marie Walsh
• Nicholas Ward, RBT
• Vanessa Washington
• Annette Marie Waterson, OTR/L
• Watkins Foot and Ankle Clinic LLC

• Psychiatry Physician in Leesburg, FL
• Providers in Leesburg, FL by specialty
• Psychiatry Physician in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 30, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.