MEDICARE: DR. WALLACE M HANDELAND O.D.

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	601000770	VA
2	152WC0802X	Corneal and Contact Management Optometrist	601000770	VA
3	152WP0200X	Pediatric Optometrist	601000770	VA
4	152WX0102X	Occupational Vision Optometrist	601000770	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	184237	OTHER	VA	ANTHEM BCBS
2	51-0558604	OTHER		TAXID CORP
3	1801903745	OTHER		GROUP NPI
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598740581
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WALLACE M HANDELAND O.D.

Provider Business Mailing Address
First Line	:	4217 VIRGINIA BEACH BLVD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-1232
Country	:	US
Telephone Number	:	757-340-7070
Fax Number	:	757-340-7500

Provider Business Practice Location Address
First Line	:	4217 VIRGINIA BEACH BLVD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-1232
Country	:	US
Telephone Number	:	757-340-7070
Fax Number	:	757-340-7500

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2005
Last Update Date	:	09/03/2008

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