Provider Demographics
NPI:1770597072
Name:BLANKENSHIP, WALTER B (OD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:B
Last Name:BLANKENSHIP
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:10485 LONGFELLOW TRCE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-9383
Mailing Address - Country:US
Mailing Address - Phone:318-524-1545
Mailing Address - Fax:318-872-0748
Practice Address - Street 1:126 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:LA
Practice Address - Zip Code:71052-2602
Practice Address - Country:US
Practice Address - Phone:318-872-0747
Practice Address - Fax:318-872-0748
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA668 107T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1072087Medicaid
LA49702Medicare ID - Type Unspecified
LA1072087Medicaid