Healthcare Provider Details

I. General information

NPI: 1578852695
Provider Name (Legal Business Name): GREGORY C WALTHER OPTOMETRIST PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2011
Last Update Date: 03/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2125 NW STEWART PKWY
ROSEBURG OR
97471-1693
US

IV. Provider business mailing address

17804 DIXONVILLE RD
ROSEBURG OR
97470-9311
US

V. Phone/Fax

Practice location:
  • Phone: 541-957-8537
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1368ATI
License Number StateOR

VIII. Authorized Official

Name: DR. GREGORY CARL WALTHER
Title or Position: PRESIDENT
Credential:
Phone: 541-957-8537