Provider Demographics
NPI:1205850781
Name:MAYO, WALTER A (OD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:A
Last Name:MAYO
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 1:1200 HIGHMARKET ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440-3227
Mailing Address - Country:US
Mailing Address - Phone:843-546-8421
Mailing Address - Fax:843-546-1173
Practice Address - Street 1:1200 HIGHMARKET ST
Practice Address - Street 2:SUITE 200
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-3227
Practice Address - Country:US
Practice Address - Phone:843-546-8421
Practice Address - Fax:843-546-1173
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC805152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD08052Medicaid
SCD08052Medicaid