Provider Demographics
NPI:1477682284
Name:RECECONI, WALTER R (OD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:R
Last Name:RECECONI
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 1:577 18TH ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-3505
Mailing Address - Country:US
Mailing Address - Phone:503-325-4401
Mailing Address - Fax:503-325-3278
Practice Address - Street 1:577 18TH ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3505
Practice Address - Country:US
Practice Address - Phone:503-325-4401
Practice Address - Fax:503-325-3278
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2022ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150738Medicaid
OR00WFBRSBMedicare ID - Type Unspecified
OR150738Medicaid