Individual
DR. LARRY CHARLES WALLIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
OD
Contact information
Practice address
14 N BROADWAY, GLOUCESTER CITY, NJ 08030-1507
(856) 456-3925
(856) 456-4748
Mailing address
PO BOX 93, 14 N BROADWAY, GLOUCESTER CITY, NJ 08030-0093
(856) 456-3925
(856) 456-4748
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
270A00350300
NJ
152W00000X
Optometrist
27T000023300
NJ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1695401
—
NJ
Enumeration date
09/19/2005
Last updated
10/30/2007
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