1093988933 NPI number — TONIALATOYA WALLACE-ELEY MD

Table of content: TONIALATOYA WALLACE-ELEY MD (NPI 1093988933)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093988933 NPI number — TONIALATOYA WALLACE-ELEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE-ELEY
Provider First Name:
TONIALATOYA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WALLACE
Provider Other First Name:
TONIALATOYA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093988933
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2030
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOMOSASSA SPRINGS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34447-2030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-621-3100
Provider Business Mailing Address Fax Number:
352-621-3121

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6201 N SUNCOAST BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRYSTAL RIVER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34428-6712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-795-6560
Provider Business Practice Location Address Fax Number:
770-776-5966
Provider Enumeration Date:
04/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X , with the licence number:  4301089191 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ME101987 . This is a "FL MEDICAL LICENSES" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 000220200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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