Robert Vernon Wallace, M. D.

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

ME0013849 Issued in FL

Practice address

400 Lee Blvd
Lehigh Acres, FL 33936-4923

Phone

(239) 369-2903

Fax

(239) 369-0500

NPI assigned

Aug 20, 2006

Last updated

Mar 7, 2023By the provider in NPPES

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Other identifiers 3

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

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

{
    "created_epoch": "1156032000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1678147200000",
    "number": "1922113174",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 848",
            "city": "LEHIGH ACRES",
            "state": "FL",
            "postal_code": "339700848",
            "telephone_number": "239-369-2903",
            "fax_number": "239-369-0500"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "400 LEE BLVD",
            "city": "LEHIGH ACRES",
            "state": "FL",
            "postal_code": "339364923",
            "telephone_number": "239-369-2903",
            "fax_number": "239-369-0500"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "ROBERT",
        "middle_name": "VERNON",
        "credential": "M. D.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-08-20",
        "last_updated": "2023-03-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "FL",
            "license": "ME0013849",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "36161",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PROFESSIONAL LICENSE",
            "identifier": "ME0013849",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AETNA",
            "identifier": "622647",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Wal-Mart Stores East LP (Walmart Pharmacy 10-2237)
• Wal-Mart Stores East, LP (Vision Center 30-2237)
• Walberto Taxi LLC
• Walgreen Co (Walgreens #06071)
• Wallace Family Practice PA
• Mark Waller, PT
• Marie Rose Walters
• Victoria Marie Ward, COTA/L
• Jovial Watson, PHARMD
• Wawa Express LLC

• Family Medicine Physician in Lehigh Acres, FL
• Providers in Lehigh Acres, FL by specialty
• Family Medicine Physician in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 7, 2023; 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.