Provider Demographics
NPI:1679511679
Name:WALLACE EYE SURGERY, LTD
Entity Type:Organization
Organization Name:WALLACE EYE SURGERY, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:318-448-4488
Mailing Address - Street 1:4110 PARLIAMENT DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-2717
Mailing Address - Country:US
Mailing Address - Phone:318-448-4488
Mailing Address - Fax:318-448-9731
Practice Address - Street 1:4110 PARLIAMENT DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-2717
Practice Address - Country:US
Practice Address - Phone:318-448-4488
Practice Address - Fax:318-448-9731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA012846207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1942006Medicaid
LA1942006Medicaid