Provider Demographics
NPI:1912014200
Name:MERRIAM, WALTER WOODHULL (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:WOODHULL
Last Name:MERRIAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5792 WIDEWATERS PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13214-1847
Mailing Address - Country:US
Mailing Address - Phone:315-422-4412
Mailing Address - Fax:315-422-4432
Practice Address - Street 1:5792 WIDEWATERS PKWY STE 101
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13214-1847
Practice Address - Country:US
Practice Address - Phone:315-422-4412
Practice Address - Fax:315-422-4432
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2019-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY114080207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00550032Medicaid
NYB81079Medicare UPIN
NY53898BMedicare ID - Type Unspecified