NPIMap

Organization Active NPI

Wallace Eye Surgery, LTD

  • Ophthalmology Physician
  • Alexandria, LA
National Provider Identifier
1679511679
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Ophthalmology PhysicianTaxonomy code 207W00000X
License
012846 Issued in LA
Legal business name
WALLACE EYE SURGERY, LTD
Practice address
4110 Parliament Dr
Alexandria, LA 71303-2717
Phone
(318) 448-4488
Fax
(318) 448-9731
NPI assigned
Jun 2, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Robert Bruce Wallace III, MDNPI 1598792293
Title
Medical Director
Phone
(318) 448-4488

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Ophthalmology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207W00000X 012846 LA Primary

Addresses

Primary practice location

4110 Parliament Dr
Alexandria, LA 71303-2717

Mailing address

4110 Parliament Dr
Alexandria, LA 71303-2717
Phone (318) 448-4488

Other identifiers 1

IdentifierTypeStateIssuer
1942006MedicaidLA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in LA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050817000469 LA Part B Supplier - Clinic/Group Practice 0042240210 Receives reassigned benefits from 6 practitioners
Practice locations: Alexandria, LA; Marksville, LA; Natchitoches, LA

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
19D2050894Wallace Eye Surgery4110 Parliament Drive, Alexandria, LA 71303Certificate of waiverDec 6, 2026

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 6

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": "1149206400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1679511679",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4110 PARLIAMENT DR",
            "city": "ALEXANDRIA",
            "state": "LA",
            "postal_code": "713032717",
            "telephone_number": "318-448-4488",
            "fax_number": "318-448-9731"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4110 PARLIAMENT DR",
            "city": "ALEXANDRIA",
            "state": "LA",
            "postal_code": "713032717",
            "telephone_number": "318-448-4488",
            "fax_number": "318-448-9731"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WALLACE EYE SURGERY, LTD",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-02",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "WALLACE",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_middle_name": "BRUCE",
        "authorized_official_title_or_position": "MEDICAL DIRECTOR",
        "authorized_official_telephone_number": "318-448-4488",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_name_suffix": "III",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207W00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Ophthalmology",
            "state": "LA",
            "license": "012846",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1942006",
            "state": "LA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Alexandria, LA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.