Provider Demographics
NPI:1568685220
Name:WALL, CHANDA PATRICIA LYNN (OD)
Entity type:Individual
Prefix:DR
First Name:CHANDA
Middle Name:PATRICIA LYNN
Last Name:WALL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:CHANDA
Other - Middle Name:WARMOTH
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:8432 LOCKWOOD RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-2903
Mailing Address - Country:US
Mailing Address - Phone:941-359-1105
Mailing Address - Fax:941-359-1229
Practice Address - Street 1:8432 LOCKWOOD RIDGE RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-2903
Practice Address - Country:US
Practice Address - Phone:941-359-1105
Practice Address - Fax:941-359-1229
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3534152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21003ZMedicare ID - Type Unspecified