Healthcare Provider Details

I. General information

NPI: 1811977937
Provider Name (Legal Business Name): WALLACE TODD COHRON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 02/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 W GL SMITH ST
MORGANTOWN KY
42261-1007
US

IV. Provider business mailing address

221 W GL SMITH ST PO BOX 1007
MORGANTOWN KY
42261-1007
US

V. Phone/Fax

Practice location:
  • Phone: 270-526-6800
  • Fax: 270-526-5462
Mailing address:
  • Phone: 270-526-6800
  • Fax: 270-526-5462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1372DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: