Provider Demographics
NPI:1457321051
Name:WALLINE, JEFFREY JAY (OD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:JAY
Last Name:WALLINE
Suffix:
Gender:M
Credentials:OD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:338 W 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1280
Mailing Address - Country:US
Mailing Address - Phone:614-247-6840
Mailing Address - Fax:614-247-6452
Practice Address - Street 1:338 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1280
Practice Address - Country:US
Practice Address - Phone:614-247-6840
Practice Address - Fax:614-247-6452
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4784152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist