Provider Demographics
NPI:1356483614
Name:ANGEL, WALTER CLARK (OD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:CLARK
Last Name:ANGEL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:2913 CHARTER OAK DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72227-3007
Mailing Address - Country:US
Mailing Address - Phone:501-223-9196
Mailing Address - Fax:501-664-3429
Practice Address - Street 1:300 S UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5209
Practice Address - Country:US
Practice Address - Phone:501-664-7217
Practice Address - Fax:501-664-3429
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARAR2005152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARU17137Medicare UPIN