MEDICARE: DR. LANDON J WALLACE 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	2934	TN

General Provider Information

NPI Number	:	1639481906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LANDON J WALLACE O.D.

Provider Business Mailing Address
First Line	:	5118 PARK AVE STE 101
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38117-5710
Country	:	US
Telephone Number	:	901-683-4529
Fax Number	:	901-767-4404

Provider Business Practice Location Address
First Line	:	5118 PARK AVE STE 101
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38117-5710
Country	:	US
Telephone Number	:	901-683-4529
Fax Number	:	901-767-4404

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

Provider Enumeration Date	:	07/02/2010
Last Update Date	:	05/11/2018

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