Provider Demographics
NPI:1487649489
Name:DUANE J WALLAKER OD
Entity Type:Organization
Organization Name:DUANE J WALLAKER OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:J
Authorized Official - Last Name:WALLAKER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:507-437-4524
Mailing Address - Street 1:510 W OAKLAND AVE
Mailing Address - Street 2:BOX 524
Mailing Address - City:AUSTIN
Mailing Address - State:MN
Mailing Address - Zip Code:55912-2314
Mailing Address - Country:US
Mailing Address - Phone:507-437-4524
Mailing Address - Fax:507-437-4525
Practice Address - Street 1:510 W OAKLAND AVE
Practice Address - Street 2:BOX 524
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912-2314
Practice Address - Country:US
Practice Address - Phone:507-437-4524
Practice Address - Fax:507-437-4525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-15
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1294152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
16412OtherUCARE MN
0182820001OtherOMERC
MN4C955WAOtherMN CARE
2292129OtherMEDICA
MN703023100Medicaid
MN32549WAOtherBLUE CROSS
585541034950OtherPREF ONE
410000678Medicare ID - Type Unspecified
MN32549WAOtherBLUE CROSS