Healthcare Provider Details

I. General information

NPI: 1689670762
Provider Name (Legal Business Name): JOHN L WALTERS OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 LOWELL ST
PORTLAND ME
04102-2748
US

IV. Provider business mailing address

15 LOWELL ST
PORTLAND ME
04102-2748
US

V. Phone/Fax

Practice location:
  • Phone: 207-774-8277
  • Fax: 207-699-5850
Mailing address:
  • Phone: 207-774-8277
  • Fax: 207-699-5850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT817
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: