Provider Demographics
NPI:1710047857
Name:TOWLE, WALLACE W (OD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:W
Last Name:TOWLE
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:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS NATIONAL PARK
Mailing Address - State:AR
Mailing Address - Zip Code:71902-0549
Mailing Address - Country:US
Mailing Address - Phone:501-624-5492
Mailing Address - Fax:501-321-0001
Practice Address - Street 1:1827 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS NATIONAL PARK
Practice Address - State:AR
Practice Address - Zip Code:71901-6848
Practice Address - Country:US
Practice Address - Phone:501-624-5492
Practice Address - Fax:501-321-0001
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2196152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR102349722Medicaid
AR48563Medicare ID - Type Unspecified
ART20210Medicare UPIN
AR0674070001Medicare NSC