Provider Demographics
NPI:1134356645
Name:WALLACE, TAMMY D (OD)
Entity type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:D
Last Name:WALLACE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:1234 ANDREWS AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:OZARK
Mailing Address - State:AL
Mailing Address - Zip Code:36360-3767
Mailing Address - Country:US
Mailing Address - Phone:334-445-3937
Mailing Address - Fax:334-445-3938
Practice Address - Street 1:1234 ANDREWS AVE
Practice Address - Street 2:SUITE E
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360-3767
Practice Address - Country:US
Practice Address - Phone:334-445-3937
Practice Address - Fax:334-445-3938
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-11
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ALS-C02152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL157145Medicaid