Provider Demographics
NPI:1568554251
Name:WALT, ROBERT H (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:H
Last Name:WALT
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 1:3232 CENTRAL BLVD
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-1439
Mailing Address - Country:US
Mailing Address - Phone:616-669-2530
Mailing Address - Fax:616-669-3646
Practice Address - Street 1:3232 CENTRAL BLVD
Practice Address - Street 2:
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-1439
Practice Address - Country:US
Practice Address - Phone:616-669-2530
Practice Address - Fax:616-669-3646
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002987152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI2987OtherEYEMED
MIP25667FOtherBLUE CARE NETWORK
MI2708884Medicaid
MI0883760001Medicare NSC
MI2708884Medicaid
MIP23350001Medicare PIN