MEDICARE: WALTER CRAIG MCCORMICK 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
1	152W00000X	Optometrist	904	NE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6885	OTHER	NE	BCBS
2	8077	OTHER	NE	MIDLANDS CHOICE

General Provider Information

NPI Number	:	1992700140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WALTER CRAIG MCCORMICK OD

Provider Business Mailing Address
First Line	:	503 MCMILLAN ST
Second Line	:
City	:	HOLDREGE
State	:	NE
Zip	:	68949-2052
Country	:	US
Telephone Number	:	308-995-8697
Fax Number	:	308-995-6931

Provider Business Practice Location Address
First Line	:	503 MCMILLAN ST
Second Line	:
City	:	HOLDREGE
State	:	NE
Zip	:	68949-2052
Country	:	US
Telephone Number	:	308-995-8697
Fax Number	:	308-995-6931

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	02/12/2008

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