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General NPI Number Information
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NPI Number | 1356485593
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Entity Type | Individual
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Provider Name | DARREN MARC WALLIS O.D.
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Gender | Male
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Dates
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Enumeration Date | 02/19/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 150 BROADWAY
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City | NEW YORK
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State | NY
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Zip | 10038-4381
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Country | US
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Telephone | 212-233-2344
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Fax |
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Provider Business Mailing Address
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Address Line | 9 LEDGEWOOD COMMONS
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City | MILLWOOD
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State | NY
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Zip | 10546-1025
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Country | US
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Telephone | 914-762-7123
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 005966
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License Number State | NY
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