Provider Demographics
NPI:1457444580
Name:PHILLIPS, WALLACE L (OD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:L
Last Name:PHILLIPS
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 1:103 S EAST AVE
Mailing Address - Street 2:
Mailing Address - City:KERMIT
Mailing Address - State:TX
Mailing Address - Zip Code:79745-3606
Mailing Address - Country:US
Mailing Address - Phone:432-586-3435
Mailing Address - Fax:432-586-6737
Practice Address - Street 1:103 S EAST AVE
Practice Address - Street 2:
Practice Address - City:KERMIT
Practice Address - State:TX
Practice Address - Zip Code:79745-3606
Practice Address - Country:US
Practice Address - Phone:432-586-3435
Practice Address - Fax:432-586-6737
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2869TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
00E80DOtherBLUE CROSS/BLUE SHIELD
TX032932801Medicaid
TX1191440001Medicare NSC
00E80DOtherBLUE CROSS/BLUE SHIELD
TXT86245Medicare UPIN