Provider Demographics
NPI:1497744791
Name:WALLACH, DIANE MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:MARIE
Last Name:WALLACH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 GRANBY ST
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23510-1805
Mailing Address - Country:US
Mailing Address - Phone:757-627-3937
Mailing Address - Fax:757-627-5689
Practice Address - Street 1:209 GRANBY ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-1805
Practice Address - Country:US
Practice Address - Phone:757-627-3937
Practice Address - Fax:757-627-5689
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001150152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA410001276Medicare PIN
U87941Medicare UPIN