Basic Information
| Provider Information | |||||||||
| NPI: | 1134356645 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | TAMMY | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 ANDREWS AVE | ||||||||
| Address2: | SUITE E | ||||||||
| City: | OZARK | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363603767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3344453937 | ||||||||
| FaxNumber: | 3344453938 | ||||||||
| Practice Location | |||||||||
| Address1: | 1234 ANDREWS AVE | ||||||||
| Address2: | SUITE E | ||||||||
| City: | OZARK | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363603767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3344453937 | ||||||||
| FaxNumber: | 3344453938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2009 | ||||||||
| LastUpdateDate: | 07/02/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | S-C02 | AL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 157145 | 05 | AL | MEDICAID |