Provider Demographics
NPI:1811985120
Name:ROBERTS, WALTER C (MD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:C
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1510 S CENTRAL AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2582
Mailing Address - Country:US
Mailing Address - Phone:213-483-2416
Mailing Address - Fax:213-483-8211
Practice Address - Street 1:1510 S CENTRAL AVE STE 100
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2582
Practice Address - Country:US
Practice Address - Phone:213-483-2416
Practice Address - Fax:213-483-8211
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG27442207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G274420Medicaid
CAG27442Medicare ID - Type Unspecified
CA00G274420Medicaid