Provider Demographics
NPI:1881655082
Name:WALTERS, RICHARD M (OD)
Entity Type:Individual
Prefix:
First Name:RICHARD
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 1:231 WINDERMERE BLVD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-3538
Mailing Address - Country:US
Mailing Address - Phone:318-487-2020
Mailing Address - Fax:318-445-7745
Practice Address - Street 1:231 WINDERMERE BLVD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303
Practice Address - Country:US
Practice Address - Phone:318-487-2020
Practice Address - Fax:318-445-7745
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA876062T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1991201Medicaid
P00169994OtherTRAVELERS MEDICARE
T19617Medicare UPIN
49107Medicare ID - Type Unspecified