Provider Demographics
NPI:1376685321
Name:THOMAS, WALTER RUSSELL (OD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:RUSSELL
Last Name:THOMAS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7610 HAZARD CENTER DR
Mailing Address - Street 2:STE. 517
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4529
Mailing Address - Country:US
Mailing Address - Phone:619-291-7712
Mailing Address - Fax:619-291-9637
Practice Address - Street 1:7610 HAZARD CENTER DR
Practice Address - Street 2:STE. 517
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4529
Practice Address - Country:US
Practice Address - Phone:619-291-7712
Practice Address - Fax:619-291-9637
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5342152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT70009Medicare UPIN