Larry Charles Wallis, OD
Individual provider Active NPI Optometrist · Gloucester City, NJ
NPI 1821083585 · NPPES record last updated Oct 30, 2007
Key facts
- NPI
- 1821083585
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Optometrist 152W00000X
- License
- 270A00350300 (NJ)
- Practice address
- 14 N Broadway
Gloucester City, NJ 08030-1507 - Phone
- (856) 456-3925
- Fax
- (856) 456-4748
- NPI assigned
- Sep 19, 2005
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 270A00350300 | NJ | MD | Optometrist |
| 27T000023300 | NJ | MD | Optometrist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Physicians Ancillary Services LLC | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | 270A00350300 | NJ | Yes |
| Optometrist | 152W00000X | 27T000023300 | NJ |
Addresses
Primary practice location
14 N Broadway
Gloucester City, NJ 08030-1507
Mailing address
PO Box 93
14 N Broadway
Gloucester City, NJ 08030-0093
Phone (856) 456-3925
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1695401 | Medicaid | NJ |
Other names
- Dr. Larry Charles Wallis
Other providers in Gloucester City, NJ
- Takeesha Danielle Thomas
- Thrive at Home Physical Therapy LLC
- Ngozi Theresa Ugoh
- Nicola Rene Visaggio
- Vital Focus Therapy, LLC
- Heather Leigh Waring
- Well Path, LLC.
- Pat Wimonsri
- Jessica Marie Zielinski
All providers in Gloucester City, NJ · Optometrist in New Jersey
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 30, 2007. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.