Provider Demographics
NPI:1144697624
Name:GEORGE W WALTERS JR
Entity type:Organization
Organization Name:GEORGE W WALTERS JR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:WATKINS
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:731-658-5197
Mailing Address - Street 1:725 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:TN
Mailing Address - Zip Code:38008-2242
Mailing Address - Country:US
Mailing Address - Phone:731-658-5197
Mailing Address - Fax:731-658-5245
Practice Address - Street 1:725 W MARKET ST
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008-2242
Practice Address - Country:US
Practice Address - Phone:731-658-5197
Practice Address - Fax:731-658-5245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-31
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD0000000654152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3594030Medicaid
TN0647480001Medicare NSC
TNT61169Medicare UPIN
TN3594030Medicare PIN