Provider Demographics
NPI:1609819952
Name:WALLACE, ROBERT BRIAN (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:BRIAN
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 1:1305 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-4528
Mailing Address - Country:US
Mailing Address - Phone:843-661-5063
Mailing Address - Fax:
Practice Address - Street 1:2014 S IRBY ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-3420
Practice Address - Country:US
Practice Address - Phone:843-679-9005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC1088152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD10888Medicaid