MEDICARE: WALLACE EYE SURGERY, LTD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	012846	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679511679
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALLACE EYE SURGERY, LTD

Provider Business Mailing Address
First Line	:	4110 PARLIAMENT DR
Second Line	:
City	:	ALEXANDRIA
State	:	LA
Zip	:	71303-2717
Country	:	US
Telephone Number	:	318-448-4488
Fax Number	:	318-448-9731

Provider Business Practice Location Address
First Line	:	4110 PARLIAMENT DR
Second Line	:
City	:	ALEXANDRIA
State	:	LA
Zip	:	71303-2717
Country	:	US
Telephone Number	:	318-448-4488
Fax Number	:	318-448-9731

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. ROBERT BRUCE WALLACE III
Credential	:	MD
Telephone Number	:	318-448-4488

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	08/22/2020

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