Provider Demographics
NPI:1649381906
Name:WALTERS, SCOTT M (OD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:M
Last Name:WALTERS
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 1:1022 NW 6TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1114
Mailing Address - Country:US
Mailing Address - Phone:541-476-4545
Mailing Address - Fax:541-479-5985
Practice Address - Street 1:1022 NW 6TH ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1114
Practice Address - Country:US
Practice Address - Phone:541-476-4545
Practice Address - Fax:541-479-5985
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2041ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR024448Medicaid
U09662Medicare UPIN
133908Medicare PIN