Provider Demographics
NPI:1255460705
Name:WALLACE, CROSBY W (OD)
Entity type:Individual
Prefix:DR
First Name:CROSBY
Middle Name:W
Last Name:WALLACE
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:6640 CYPRESSWOOD DR
Mailing Address - Street 2:STE 105
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77379-7738
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6640 CYPRESSWOOD DR
Practice Address - Street 2:STE 105
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77379-7738
Practice Address - Country:US
Practice Address - Phone:281-355-9090
Practice Address - Fax:281-602-8419
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX5527TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist