Provider Demographics
NPI:1285675827
Name:WALLACE, JAMES WINCHESTER (OD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:WINCHESTER
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 1:1450 E GENEVA ST
Mailing Address - Street 2:
Mailing Address - City:DELAVAN
Mailing Address - State:WI
Mailing Address - Zip Code:53115-2025
Mailing Address - Country:US
Mailing Address - Phone:262-728-0068
Mailing Address - Fax:262-728-0055
Practice Address - Street 1:1450 E GENEVA ST
Practice Address - Street 2:
Practice Address - City:DELAVAN
Practice Address - State:WI
Practice Address - Zip Code:53115-2025
Practice Address - Country:US
Practice Address - Phone:262-728-0068
Practice Address - Fax:262-728-0055
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2267152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3857500Medicaid
WIT86522Medicare UPIN