Provider Demographics
NPI:1639210164
Name:WALT, DAWN K (OD)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:K
Last Name:WALT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:692 W RANDALL ST
Mailing Address - Street 2:
Mailing Address - City:COOPERSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49404-1306
Mailing Address - Country:US
Mailing Address - Phone:616-837-6847
Mailing Address - Fax:616-837-9338
Practice Address - Street 1:692 W RANDALL ST
Practice Address - Street 2:
Practice Address - City:COOPERSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49404-1306
Practice Address - Country:US
Practice Address - Phone:616-837-6847
Practice Address - Fax:616-837-9338
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002956152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900G065080OtherBCBS
MIP00109551OtherRR MEDICARE
MIP00109551OtherRR MEDICARE
MIT33522Medicare UPIN
MI0N55960Medicare PIN