Provider Demographics
NPI:1609840735
Name:JAY, WALTER M (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:M
Last Name:JAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:WALTER
Other - Middle Name:M
Other - Last Name:JAKUBAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2160 S 1ST AVE
Mailing Address - Street 2:(9806 ROBERTS RD., HICKOTY HILLS, IL. 60457)
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:708-233-5333
Mailing Address - Fax:708-233-5348
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:(9806 ROBERTS RD., HICKOTY HILLS, IL. 60457)
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-233-5333
Practice Address - Fax:708-233-5348
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36055023207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36055023Medicaid
IL36055023Medicaid
D45749Medicare UPIN