Provider Demographics
NPI:1760435143
Name:CHRISTENSEN, WALLACE LLOYD (OD)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:LLOYD
Last Name:CHRISTENSEN
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 1:1246 YELLOWSTONE AVE
Mailing Address - Street 2:SUITE A4
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4374
Mailing Address - Country:US
Mailing Address - Phone:208-237-7666
Mailing Address - Fax:208-237-7400
Practice Address - Street 1:1246 YELLOWSTONE AVE
Practice Address - Street 2:SUITE A4
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4374
Practice Address - Country:US
Practice Address - Phone:208-237-7666
Practice Address - Fax:208-237-7400
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP0721152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002875500Medicaid
IDT44372Medicare UPIN
ID002875500Medicaid