Provider Demographics
NPI:1457603797
Name:DALKE, JUSTIN COLIN (OD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:COLIN
Last Name:DALKE
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 1:22 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2816
Mailing Address - Country:US
Mailing Address - Phone:509-529-2020
Mailing Address - Fax:509-529-2115
Practice Address - Street 1:22 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2816
Practice Address - Country:US
Practice Address - Phone:509-529-2020
Practice Address - Fax:509-529-2115
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60566861152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2046879Medicaid