Provider Demographics
NPI:1649315920
Name:WALLIS, KIRK D (RDO)
Entity type:Individual
Prefix:
First Name:KIRK
Middle Name:D
Last Name:WALLIS
Suffix:
Gender:M
Credentials:RDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44407 10TH ST W
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-3345
Mailing Address - Country:US
Mailing Address - Phone:661-942-6515
Mailing Address - Fax:661-723-9293
Practice Address - Street 1:44407 10TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-3345
Practice Address - Country:US
Practice Address - Phone:661-942-6515
Practice Address - Fax:661-723-9293
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6273156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ35826ZMedicaid