Provider Demographics
NPI:1780680843
Name:WALTON, THEODORE B JR (OD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:B
Last Name:WALTON
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:837 S LAPEER RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-5084
Mailing Address - Country:US
Mailing Address - Phone:248-628-3441
Mailing Address - Fax:248-628-5105
Practice Address - Street 1:837 S LAPEER RD
Practice Address - Street 2:STE 101
Practice Address - City:OXFORD
Practice Address - State:MI
Practice Address - Zip Code:48371-5084
Practice Address - Country:US
Practice Address - Phone:248-628-3441
Practice Address - Fax:248-628-5105
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002241152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI147436OtherCOLE
MI5012274Medicaid
MITW002241OtherBCBS
MI230462OtherNVA
MI5012274Medicaid
MI230462OtherNVA