Provider Demographics
NPI:1992741250
Name:WALLS, WADE A (OD)
Entity type:Individual
Prefix:
First Name:WADE
Middle Name:A
Last Name:WALLS
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 1:2222 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-1619
Mailing Address - Country:US
Mailing Address - Phone:918-542-1929
Mailing Address - Fax:918-542-7796
Practice Address - Street 1:2222 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-1619
Practice Address - Country:US
Practice Address - Phone:918-542-1929
Practice Address - Fax:918-542-7796
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK 2235152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKU66685Medicare UPIN