Provider Demographics
NPI:1851555106
Name:WALLY, RYAN SHELTON (OD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:SHELTON
Last Name:WALLY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2167 S LAMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5223
Mailing Address - Country:US
Mailing Address - Phone:662-234-6683
Mailing Address - Fax:662-234-6683
Practice Address - Street 1:2167 S LAMAR BLVD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5223
Practice Address - Country:US
Practice Address - Phone:662-234-6683
Practice Address - Fax:662-234-6683
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-16
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS796152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist