Provider Demographics
NPI:1225045164
Name:WALLACE, ALLAN M (OD)
Entity Type:Individual
Prefix:DR
First Name:ALLAN
Middle Name:M
Last Name:WALLACE
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 1:605 STEAMBOAT CT
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76006-3761
Mailing Address - Country:US
Mailing Address - Phone:817-551-5600
Mailing Address - Fax:
Practice Address - Street 1:11803 SOUTH FRWY
Practice Address - Street 2:SUITE 114
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115
Practice Address - Country:US
Practice Address - Phone:817-551-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2898TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00E37EOtherBCBS