Basic Information
| Provider Information | |||||||||
| NPI: | 1851327332 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHILIPS | ||||||||
| FirstName: | WALLACE | ||||||||
| MiddleName: | M | ||||||||
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| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1255 CORPORATE DR | ||||||||
| Address2: | THIRD FLOOR | ||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750382518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727911224 | ||||||||
| FaxNumber: | 8775945434 | ||||||||
| Practice Location | |||||||||
| Address1: | 1021 E ROBINSON ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328012004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078414022 | ||||||||
| FaxNumber: | 4078395074 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | ME14099 | FL | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.