Provider Demographics
NPI:1811997752
Name:BALL, WALTER LEE JR (OD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:LEE
Last Name:BALL
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:7500 CENTURION PARKWAY
Mailing Address - Street 2:SUITE 100 DACAF
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0517
Mailing Address - Country:US
Mailing Address - Phone:904-443-1383
Mailing Address - Fax:904-928-5805
Practice Address - Street 1:7500 CENTURION PARKWAY
Practice Address - Street 2:SUITE 100 DACAF
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-0517
Practice Address - Country:US
Practice Address - Phone:904-443-1383
Practice Address - Fax:904-928-5805
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4348152W00000X
FLOPC3639152W00000X
NC2141152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0323471Medicaid
MA0323471Medicaid
U92255Medicare UPIN