Provider Demographics
NPI:1437336088
Name:WALTON, TERRY L (OD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:L
Last Name:WALTON
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 1:575 GLEN ST
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-2243
Mailing Address - Country:US
Mailing Address - Phone:518-792-0518
Mailing Address - Fax:518-792-4739
Practice Address - Street 1:575 GLEN ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-2243
Practice Address - Country:US
Practice Address - Phone:518-792-0518
Practice Address - Fax:518-792-4739
Is Sole Proprietor?:No
Enumeration Date:2008-01-25
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV003045-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00406400Medicaid
NY32774BMedicare PIN
NY00406400Medicaid