Healthcare Provider Details

I. General information

NPI: 1487649489
Provider Name (Legal Business Name): DUANE J WALLAKER OD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 03/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 W OAKLAND AVE BOX 524
AUSTIN MN
55912-2314
US

IV. Provider business mailing address

510 W OAKLAND AVE BOX 524
AUSTIN MN
55912-2314
US

V. Phone/Fax

Practice location:
  • Phone: 507-437-4524
  • Fax: 507-437-4525
Mailing address:
  • Phone: 507-437-4524
  • Fax: 507-437-4525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1294
License Number StateMN

VIII. Authorized Official

Name: DR. DUANE J WALLAKER
Title or Position: OWNER
Credential: OD
Phone: 507-437-4524