Provider Demographics
NPI:1003837733
Name:WALLING, PHILIP E (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:E
Last Name:WALLING
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1124 S STATE ST
Mailing Address - Street 2:MCO 101H
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-2256
Mailing Address - Country:US
Mailing Address - Phone:231-591-2020
Mailing Address - Fax:231-591-3991
Practice Address - Street 1:1124 S STATE ST
Practice Address - Street 2:MCO 101H
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-2256
Practice Address - Country:US
Practice Address - Phone:231-591-2020
Practice Address - Fax:231-591-3991
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003260152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0784610001030OtherADMINISTAR
MI4401699Medicaid
MI999998001OtherVSP
MIPW003260OtherBLUE CROSS
MI900006367OtherPRIORITY HEALTH
MIPW003260OtherBLUE CROSS
T91189Medicare UPIN