Healthcare Provider Details

I. General information

NPI: 1083770119
Provider Name (Legal Business Name): WALTER ERNEST BALFOUR O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 W COAL AVE
GALLUP NM
87301-6305
US

IV. Provider business mailing address

219 W COAL AVE
GALLUP NM
87301-6305
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-6448
  • Fax: 505-722-6491
Mailing address:
  • Phone: 505-863-6448
  • Fax: 505-722-6491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number240
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: