Provider Demographics
NPI:1417173832
Name:WALTERS, STACI RENEE (OD)
Entity Type:Individual
Prefix:DR
First Name:STACI
Middle Name:RENEE
Last Name:WALTERS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 S APOLLO BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-1485
Mailing Address - Country:US
Mailing Address - Phone:321-984-3200
Mailing Address - Fax:321-984-0032
Practice Address - Street 1:665 S APOLLO BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1485
Practice Address - Country:US
Practice Address - Phone:321-984-3200
Practice Address - Fax:321-984-0032
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4395152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL053998005OtherDEMERC PB
FL190CMOtherBCBS
FL053998004OtherDEMERC ST
FL053998002OtherDEMERC AP
FL053998003OtherDEMERC NC
FL003325900Medicaid
FL0539980006OtherDEMERC TV
FL053998004OtherDEMERC ST
FL053998002OtherDEMERC AP