Provider Demographics
NPI:1639481906
Name:WALLACE, LANDON J (OD)
Entity Type:Individual
Prefix:DR
First Name:LANDON
Middle Name:J
Last Name:WALLACE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5118 PARK AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-5710
Mailing Address - Country:US
Mailing Address - Phone:901-683-4529
Mailing Address - Fax:901-767-4404
Practice Address - Street 1:5118 PARK AVE STE 101
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-5710
Practice Address - Country:US
Practice Address - Phone:901-683-4529
Practice Address - Fax:901-767-4404
Is Sole Proprietor?:No
Enumeration Date:2010-07-02
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist