MEDICARE: DUANE J WALLAKER OD

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	152W00000X	Optometrist	1294	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	16412	OTHER		UCARE MN
2	0182820001	OTHER		OMERC
3	4C955WA	OTHER	MN	MN CARE
4	2292129	OTHER		MEDICA
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	32549WA	OTHER	MN	BLUE CROSS
7	585541034950	OTHER		PREF ONE

General Provider Information

NPI Number	:	1487649489
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DUANE J WALLAKER OD

Provider Business Mailing Address
First Line	:	510 W OAKLAND AVE
Second Line	:	BOX 524
City	:	AUSTIN
State	:	MN
Zip	:	55912-2314
Country	:	US
Telephone Number	:	507-437-4524
Fax Number	:	507-437-4525

Provider Business Practice Location Address
First Line	:	510 W OAKLAND AVE
Second Line	:	BOX 524
City	:	AUSTIN
State	:	MN
Zip	:	55912-2314
Country	:	US
Telephone Number	:	507-437-4524
Fax Number	:	507-437-4525

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DUANE J WALLAKER
Credential	:	OD
Telephone Number	:	507-437-4524

Provider Enumeration Date	:	09/15/2005
Last Update Date	:	03/31/2008

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