Active NPI
Wallace L Phillips, O.D.
- Optometrist
- Kermit, TX
National Provider Identifier
1457444580
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Optometrist
- License
- 2869TG
- Practice address
- 103 S East Ave
Kermit, TX 79745-3606 - Phone
- (432) 586-3435
- Fax
- (432) 586-6737
- NPI assigned
- Oct 2, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | 2869TG | TX | Primary |
Addresses
Primary practice location
103 S East Ave
Kermit, TX 79745-3606
Mailing address
103 S East Ave
Kermit, TX 79745-3606
Phone (432) 586-3435
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 00E80D | Other | BLUE CROSS/BLUE SHIELD | |
| 032932801 | Medicaid | TX |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in TX
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20101101000025 | TX | Practitioner - Optometry | 7113035817 |
Receives reassigned benefits from 1 practitioner Practice locations: Kermit, TX |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2869TG | TX | MD | Optometrist |
Practitioners & affiliated clinicians
Practitioners 1
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1159747200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1278374400000",
"number": "1457444580",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "103 S EAST AVE",
"city": "KERMIT",
"state": "TX",
"postal_code": "797453606",
"telephone_number": "432-586-3435",
"fax_number": "432-586-6737"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "103 S EAST AVE",
"city": "KERMIT",
"state": "TX",
"postal_code": "797453606",
"telephone_number": "432-586-3435",
"fax_number": "432-586-6737"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PHILLIPS",
"first_name": "WALLACE",
"middle_name": "L",
"credential": "O.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-10-02",
"last_updated": "2010-07-06",
"status": "A"
},
"taxonomies": [
{
"code": "152W00000X",
"taxonomy_group": "",
"desc": "Optometrist",
"state": "TX",
"license": "2869TG",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS/BLUE SHIELD",
"identifier": "00E80D",
"state": null
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "032932801",
"state": "TX"
}
],
"endpoints": [],
"other_names": []
}Other providers in Kermit, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 6, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.