Provider Demographics
NPI:1982214045
Name:WALD, JESSE JAMES (OD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:JAMES
Last Name:WALD
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 1:212 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:OK
Mailing Address - Zip Code:73651-3628
Mailing Address - Country:US
Mailing Address - Phone:580-726-3301
Mailing Address - Fax:580-726-3302
Practice Address - Street 1:212 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:OK
Practice Address - Zip Code:73651-3628
Practice Address - Country:US
Practice Address - Phone:580-726-3301
Practice Address - Fax:580-726-3302
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3103152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist