Provider Demographics
NPI:1689615346
Name:WALLACE, MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
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 1:1379 FLUSHING RD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433-2262
Mailing Address - Country:US
Mailing Address - Phone:810-659-3135
Mailing Address - Fax:810-659-0024
Practice Address - Street 1:1379 FLUSHING RD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:MI
Practice Address - Zip Code:48433-2262
Practice Address - Country:US
Practice Address - Phone:810-659-3135
Practice Address - Fax:810-659-0024
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003070152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI944885903Medicaid
MI900B514120OtherBLUE CARE NETWORK
OH2678599Medicaid
MI900B566350OtherBCBS OF MI
OH2678599Medicaid
MIP31450001Medicare PIN
MI900B514120OtherBLUE CARE NETWORK
OHP00374947Medicare PIN
MI0N21210001Medicare PIN