Provider Demographics
NPI:1841249729
Name:WALLIS, STEVEN B (OD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:B
Last Name:WALLIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:15972 TUSCOLA RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307
Mailing Address - Country:US
Mailing Address - Phone:760-946-2700
Mailing Address - Fax:760-946-3355
Practice Address - Street 1:15972 TUSCOLA RD
Practice Address - Street 2:SUITE 101
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307
Practice Address - Country:US
Practice Address - Phone:760-946-2700
Practice Address - Fax:760-946-3355
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA7082T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA330505280OtherBLUE CROSS BLUE SHIELD
CASD0070820Medicaid
CASD0070821OtherMEDICARE PTAN
CASD0070820Medicaid