Healthcare Provider Details

I. General information

NPI: 1891748067
Provider Name (Legal Business Name): RONALD CHARLES WALLIE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 02/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 W BROAD ST SUITE A
NEWTON FALLS OH
44444-1572
US

IV. Provider business mailing address

115 W BROAD ST SUITE A
NEWTON FALLS OH
44444-1572
US

V. Phone/Fax

Practice location:
  • Phone: 330-872-1371
  • Fax: 330-872-1248
Mailing address:
  • Phone: 330-872-1371
  • Fax: 330-872-1248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3576/T1280
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number3576/T1280
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: