Individual
LARRY B WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
OD
Contact information
Practice address
322 N AURORA ST, ITHACA, NY 14850-4202
(607) 277-4749
(607) 277-5216
Mailing address
322 N. AURORA ST., ITHACA, NY 14850
(607) 277-4749
(607) 277-5216
Taxonomy
Speciality
Code
Description
License number
State
152WL0500X
Low Vision Rehabilitation Optometrist
VUT003212
NY
152WV0400X
Vision Therapy Optometrist
Primary
VUT003212
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
T003212-1
NY STATE LICENSE
NY
Enumeration date
07/07/2006
Last updated
10/06/2010
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