Provider Demographics
NPI:1891841912
Name:WALTERS, MARIE B (OD)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:B
Last Name:WALTERS
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 1:140 MACOMB
Mailing Address - Street 2:
Mailing Address - City:MT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043
Mailing Address - Country:US
Mailing Address - Phone:586-468-7370
Mailing Address - Fax:586-464-1472
Practice Address - Street 1:18645 W WARREN AVE
Practice Address - Street 2:SVS VISION INC
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228
Practice Address - Country:US
Practice Address - Phone:313-240-7551
Practice Address - Fax:313-240-8621
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002627152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI944737405Medicaid