Provider Demographics
NPI:1356317937
Name:WALLIS, WILLIAM ROBERT CHRISTOPHER (OD)
Entity Type:Individual
Prefix:
First Name:WILLIAM ROBERT
Middle Name:CHRISTOPHER
Last Name:WALLIS
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 1:838 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701
Mailing Address - Country:US
Mailing Address - Phone:740-452-9319
Mailing Address - Fax:740-452-2427
Practice Address - Street 1:838 MARKET ST
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701
Practice Address - Country:US
Practice Address - Phone:740-452-9319
Practice Address - Fax:740-452-2427
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH340049262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0940245Medicaid
OHWA0749633Medicare ID - Type Unspecified
OH0940245Medicaid