Provider Demographics
NPI:1477535383
Name:KNAPP, WALLACE JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:JOHN
Last Name:KNAPP
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:PO BOX 540
Mailing Address - Street 2:
Mailing Address - City:UPPER SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:43351-0540
Mailing Address - Country:US
Mailing Address - Phone:419-294-2421
Mailing Address - Fax:419-294-2499
Practice Address - Street 1:212 E WYANDOT AVE
Practice Address - Street 2:
Practice Address - City:UPPER SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:43351-1432
Practice Address - Country:US
Practice Address - Phone:419-294-2421
Practice Address - Fax:419-294-2499
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2913/T826152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0144114Medicaid
T46651Medicare UPIN
OH0398114Medicare PIN