Provider Demographics
NPI:1164421319
Name:RYNE, WALLACE R (OD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:R
Last Name:RYNE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6452 ALEXANDRA MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76131-1221
Mailing Address - Country:US
Mailing Address - Phone:817-232-3203
Mailing Address - Fax:
Practice Address - Street 1:1980 E NORTHWEST PKWY
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6510
Practice Address - Country:US
Practice Address - Phone:817-329-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX02485TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXMR0384545OtherDEA
TXMR0384545OtherDEA
TXT15895Medicare UPIN