Provider Demographics
NPI:1639158959
Name:WALTERS, ROLAND A (MD)
Entity Type:Individual
Prefix:
First Name:ROLAND
Middle Name:A
Last Name:WALTERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3301 NW 63RD ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-3705
Mailing Address - Country:US
Mailing Address - Phone:405-949-6177
Mailing Address - Fax:405-949-6376
Practice Address - Street 1:3301 NW 63RD ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-3705
Practice Address - Country:US
Practice Address - Phone:405-949-6177
Practice Address - Fax:405-949-6376
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-13
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK9007207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK$$$$$$$$$Medicare PIN
OKD35382Medicare UPIN