=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831408186
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY J WALPORT O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2010
-----------------------------------------------------
Last Update Date | 10/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12523 LIMONITE AVE STE 460
-----------------------------------------------------
City | MIRA LOMA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91752-3668
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-685-9645
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1119 NEATHERLY CIR
-----------------------------------------------------
City | CORONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92880-1240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-504-2789
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 14018TLG
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------