Provider Demographics
NPI:1124101860
Name:WALTHER, DEAN (OD)
Entity type:Individual
Prefix:DR
First Name:DEAN
Middle Name:
Last Name:WALTHER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEIPSIC
Mailing Address - State:OH
Mailing Address - Zip Code:45856-1428
Mailing Address - Country:US
Mailing Address - Phone:419-943-3697
Mailing Address - Fax:
Practice Address - Street 1:109 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LEIPSIC
Practice Address - State:OH
Practice Address - Zip Code:45856-1428
Practice Address - Country:US
Practice Address - Phone:419-943-3697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4420 T995152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHU38541Medicare UPIN
OH0731443Medicare ID - Type Unspecified