Healthcare Provider Details

I. General information

NPI: 1437336088
Provider Name (Legal Business Name): TERRY L WALTON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2008
Last Update Date: 04/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 GLEN ST
GLENS FALLS NY
12801-2243
US

IV. Provider business mailing address

575 GLEN ST
GLENS FALLS NY
12801-2243
US

V. Phone/Fax

Practice location:
  • Phone: 518-792-0518
  • Fax: 518-792-4739
Mailing address:
  • Phone: 518-792-0518
  • Fax: 518-792-4739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV003045-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: