Provider Demographics
NPI:1497850085
Name:WALLACE, FRED (OD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:
Last Name:WALLACE
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 1:1431 2ND AVE N
Mailing Address - Street 2:
Mailing Address - City:BESSEMER
Mailing Address - State:AL
Mailing Address - Zip Code:35020-5608
Mailing Address - Country:US
Mailing Address - Phone:205-425-5182
Mailing Address - Fax:205-426-5013
Practice Address - Street 1:1431 2ND AVE N
Practice Address - Street 2:
Practice Address - City:BESSEMER
Practice Address - State:AL
Practice Address - Zip Code:35020-5608
Practice Address - Country:US
Practice Address - Phone:205-425-5182
Practice Address - Fax:205-426-5013
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-517-TA-090152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051059719OtherBLUE CROSS
AL000059719Medicaid
ALP00077951OtherRAILROAD
ALT69097Medicare UPIN
AL000059719Medicare PIN