Provider Demographics
NPI:1578535746
Name:AWALT, WARREN DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:WARREN
Middle Name:DAVID
Last Name:AWALT
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 1:1422 B LOOP 336 W
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304
Mailing Address - Country:US
Mailing Address - Phone:936-539-2020
Mailing Address - Fax:936-756-7916
Practice Address - Street 1:1422 B LOOP 336 W
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304
Practice Address - Country:US
Practice Address - Phone:936-539-2020
Practice Address - Fax:936-756-7916
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4217T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU13660Medicare UPIN
TX8B4199Medicare PIN