Provider Demographics
NPI:1477657013
Name:GARY P WALKER OD PC
Entity Type:Organization
Organization Name:GARY P WALKER OD PC
Other - Org Name:EASTLAND VISION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:P
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-733-1944
Mailing Address - Street 1:1067 EASTLAND DR
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6747
Mailing Address - Country:US
Mailing Address - Phone:208-733-1944
Mailing Address - Fax:208-734-4984
Practice Address - Street 1:1067 EASTLAND DR
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6747
Practice Address - Country:US
Practice Address - Phone:208-733-1944
Practice Address - Fax:208-734-4984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-0539152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1477657013Medicaid
ID806642800Medicaid