Provider Demographics
NPI:1972638724
Name:WALLINGTON, EDWIN RUSSELL (OD)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:RUSSELL
Last Name:WALLINGTON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:265 MEADOWVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ATTICA
Mailing Address - State:MI
Mailing Address - Zip Code:48412-9627
Mailing Address - Country:US
Mailing Address - Phone:810-667-4194
Mailing Address - Fax:
Practice Address - Street 1:600 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-2463
Practice Address - Country:US
Practice Address - Phone:810-667-4777
Practice Address - Fax:810-667-4770
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003847152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM89340Medicare ID - Type Unspecified
MIU74679Medicare UPIN