Provider Demographics
NPI:1356485593
Name:WALLIS, DARREN MARC (OD)
Entity Type:Individual
Prefix:DR
First Name:DARREN
Middle Name:MARC
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 1:9 LEDGEWOOD COMMONS
Mailing Address - Street 2:
Mailing Address - City:MILLWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:10546-1025
Mailing Address - Country:US
Mailing Address - Phone:914-762-7123
Mailing Address - Fax:
Practice Address - Street 1:150 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-4381
Practice Address - Country:US
Practice Address - Phone:212-233-2344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005966152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist