Individual
DR. MICHAEL WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
1379 FLUSHING RD, FLUSHING, MI 48433-2262
(810) 659-3135
(810) 659-0024
Mailing address
1379 FLUSHING RD, FLUSHING, MI 48433-2262
(810) 659-3135
(810) 659-0024
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
4901003070
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2678599
—
OH
01
—
900B514120
BLUE CARE NETWORK
MI
01
—
900B566350
BCBS OF MI
MI
05
—
944885903
—
MI
Enumeration date
06/10/2006
Last updated
05/07/2009
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