Provider Demographics
NPI:1053549212
Name:WALLACE, MOIRA PETIRS (MD)
Entity type:Individual
Prefix:
First Name:MOIRA
Middle Name:PETIRS
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830-13 A1A NORTH
Mailing Address - Street 2:232
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32082
Mailing Address - Country:US
Mailing Address - Phone:714-342-3689
Mailing Address - Fax:
Practice Address - Street 1:3625 UNIVERSITY BLVD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4207
Practice Address - Country:US
Practice Address - Phone:904-702-6111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA120516207P00000X
FLME133941207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine