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NPI Code Detail

MEDICARE: DR. JENNIFER WALLER OD

MEDICARE: DR. JENNIFER WALLER OD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1152W00000XOptometrist046009087IL

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1410038558OTHERILRAILROAD MEDICARE - GRD
3410038559OTHERILRAILROAD MEDICARE - SPFLD

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1861440612
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JENNIFER WALLER OD
Provider Business Mailing Address
First Line : 600 S 8TH ST
Second Line :
City : BENLD
State : IL
Zip : 62009-1446
Country : US
Telephone Number : 217-835-7724
Fax Number : 217-835-7611
Provider Business Practice Location Address
First Line : 2020 W ILES AVE
Second Line :
City : SPRINGFIELD
State : IL
Zip : 62704-4174
Country : US
Telephone Number : 217-698-3030
Fax Number : 217-698-3068
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/04/2006
Last Update Date : 02/03/2023

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