Provider Demographics
NPI:1972717544
Name:WALLACH, DAVID (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:WALLACH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6939 173RD ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11365-3432
Mailing Address - Country:US
Mailing Address - Phone:718-739-5454
Mailing Address - Fax:718-526-1818
Practice Address - Street 1:16820 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-5216
Practice Address - Country:US
Practice Address - Phone:718-739-5454
Practice Address - Fax:718-526-1818
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV004825152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01178821Medicaid
NYT89740Medicare UPIN
NY01178821Medicaid