Provider Demographics
NPI:1245386549
Name:DONACH, WALTER (OD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:DONACH
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 1:17 SPARROW LN
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11797-3206
Mailing Address - Country:US
Mailing Address - Phone:516-528-3695
Mailing Address - Fax:516-224-0991
Practice Address - Street 1:6110 BERGENLINE AVE
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-1568
Practice Address - Country:US
Practice Address - Phone:201-861-1144
Practice Address - Fax:201-868-3577
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJOA-004538152W00000X
NYTUV-004396152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0515205Medicaid
NJ0515205Medicaid
NJ034445Medicare PIN