MEDICARE: DR. MICHAEL 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	4901003070	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	900B514120	OTHER	MI	BLUE CARE NETWORK
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	900B566350	OTHER	MI	BCBS OF MI

General Provider Information

NPI Number	:	1689615346
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL WALLACE O.D.

Provider Business Mailing Address
First Line	:	1379 FLUSHING RD
Second Line	:
City	:	FLUSHING
State	:	MI
Zip	:	48433-2262
Country	:	US
Telephone Number	:	810-659-3135
Fax Number	:	810-659-0024

Provider Business Practice Location Address
First Line	:	1379 FLUSHING RD
Second Line	:
City	:	FLUSHING
State	:	MI
Zip	:	48433-2262
Country	:	US
Telephone Number	:	810-659-3135
Fax Number	:	810-659-0024

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

Provider Enumeration Date	:	06/10/2006
Last Update Date	:	05/07/2009

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