Provider Demographics
NPI:1912687179
Name:WALLACE, SIMONE ALISHA (OD)
Entity Type:Individual
Prefix:MISS
First Name:SIMONE
Middle Name:ALISHA
Last Name:WALLACE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:462 N TERRY AVE APT 1214
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-2069
Mailing Address - Country:US
Mailing Address - Phone:267-597-8430
Mailing Address - Fax:
Practice Address - Street 1:3226 E COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-5110
Practice Address - Country:US
Practice Address - Phone:407-203-5801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC6305152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist