Provider Demographics
NPI:1205947603
Name:WOLLEAT, WALTER R (OD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:R
Last Name:WOLLEAT
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 1:28356 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-1434
Mailing Address - Country:US
Mailing Address - Phone:310-831-0841
Mailing Address - Fax:310-831-3369
Practice Address - Street 1:28356 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:RANCHO PALOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275-1434
Practice Address - Country:US
Practice Address - Phone:310-831-0841
Practice Address - Fax:310-831-3369
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOP5349T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0409420-001OtherCIGNA
CA0409420-001OtherCIGNA
CAOP5349TMedicare ID - Type Unspecified