Provider Demographics
NPI:1083797971
Name:WALD, JOSEPH S (OD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:S
Last Name:WALD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 S ALDER ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:BURLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98233-2808
Mailing Address - Country:US
Mailing Address - Phone:360-755-9211
Mailing Address - Fax:360-755-0501
Practice Address - Street 1:855 S ALDER ST
Practice Address - Street 2:SUITE A
Practice Address - City:BURLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98233-2808
Practice Address - Country:US
Practice Address - Phone:360-755-9211
Practice Address - Fax:360-755-0501
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3634152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2029593Medicaid
U27352Medicare UPIN
8850990Medicare ID - Type Unspecified
WAG8850990Medicare PIN