Provider Demographics
NPI:1134142094
Name:WALTERS, JR, GEORGE W (OD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:W
Last Name:WALTERS, JR
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:PO BOX C
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:TN
Mailing Address - Zip Code:38008-0391
Mailing Address - Country:US
Mailing Address - Phone:731-658-5197
Mailing Address - Fax:731-658-5245
Practice Address - Street 1:725 W MARKET ST
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008-2242
Practice Address - Country:US
Practice Address - Phone:731-658-5197
Practice Address - Fax:731-658-5245
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD0000000654152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3594030Medicaid
TN0647480001Medicare NSC
TNT61169Medicare UPIN
TN3594030Medicaid