Provider Demographics
NPI:1972596369
Name:TERRY L WALTON DOCTOR OF OPTOMETRY PC
Entity Type:Organization
Organization Name:TERRY L WALTON DOCTOR OF OPTOMETRY PC
Other - Org Name:ASSOCIATES IN VISION CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:518-792-0518
Mailing Address - Street 1:575 GLEN ST
Mailing Address - Street 2:BOX 2071
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-2243
Mailing Address - Country:US
Mailing Address - Phone:518-792-0518
Mailing Address - Fax:518-792-4739
Practice Address - Street 1:575 GLEN ST
Practice Address - Street 2:BOX 2071
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-2243
Practice Address - Country:US
Practice Address - Phone:518-792-0518
Practice Address - Fax:518-792-4739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYUT003045-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02376218Medicaid
NY02376218Medicaid
NY32774AMedicare PIN
NY0892470001Medicare NSC