Provider Demographics
NPI:1356442917
Name:WALKER, BROOK EDWARD (OD)
Entity type:Individual
Prefix:DR
First Name:BROOK
Middle Name:EDWARD
Last Name:WALKER
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 1:1815 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98248-9454
Mailing Address - Country:US
Mailing Address - Phone:360-393-4000
Mailing Address - Fax:360-393-4004
Practice Address - Street 1:1815 MAIN ST
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:WA
Practice Address - Zip Code:98248-9454
Practice Address - Country:US
Practice Address - Phone:360-393-4000
Practice Address - Fax:360-393-4004
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA4007152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2006335Medicaid
WA2006626Medicaid
WA2006335Medicaid
WA6253220001Medicare NSC
WA2006626Medicaid
WAG8881932Medicare PIN