Provider Demographics
NPI:1821083585
Name:WALLIS, LARRY CHARLES (OD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:CHARLES
Last Name:WALLIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:LARRY
Other - Middle Name:CHARLES
Other - Last Name:WALLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 93
Mailing Address - Street 2:14 N BROADWAY
Mailing Address - City:GLOUCESTER CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08030-0093
Mailing Address - Country:US
Mailing Address - Phone:856-456-3925
Mailing Address - Fax:856-456-4748
Practice Address - Street 1:14 N BROADWAY
Practice Address - Street 2:
Practice Address - City:GLOUCESTER CITY
Practice Address - State:NJ
Practice Address - Zip Code:08030-1507
Practice Address - Country:US
Practice Address - Phone:856-456-3925
Practice Address - Fax:856-456-4748
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-19
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ270A00350300152W00000X
NJ27T000023300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1695401Medicaid
NJ054627Medicare PIN
NJ1695401Medicaid