Provider Demographics
NPI:1891748067
Name:WALLIE, RONALD CHARLES (OD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:CHARLES
Last Name:WALLIE
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 1:115 W BROAD ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWTON FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44444-1572
Mailing Address - Country:US
Mailing Address - Phone:330-872-1371
Mailing Address - Fax:330-872-1248
Practice Address - Street 1:115 W BROAD ST
Practice Address - Street 2:SUITE A
Practice Address - City:NEWTON FALLS
Practice Address - State:OH
Practice Address - Zip Code:44444-1572
Practice Address - Country:US
Practice Address - Phone:330-872-1371
Practice Address - Fax:330-872-1248
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3576/T1280152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0481072Medicaid
OHWA0686174Medicare ID - Type Unspecified
OH0481072Medicaid