Basic Information
| Provider Information | |||||||||
| NPI: | 1891841912 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTERS | ||||||||
| FirstName: | MARIE | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 MACOMB | ||||||||
| Address2: | |||||||||
| City: | MT CLEMENS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864687370 | ||||||||
| FaxNumber: | 5864641472 | ||||||||
| Practice Location | |||||||||
| Address1: | 18645 W WARREN AVE | ||||||||
| Address2: | SVS VISION INC | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132407551 | ||||||||
| FaxNumber: | 3132408621 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 08/19/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4901002627 | MI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 944737405 | 05 | MI | MEDICAID |