Provider Demographics
NPI:1194750406
Name:WALTERS, MARY COLLEEN (OD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:COLLEEN
Last Name:WALTERS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:M.
Other - Middle Name:COLLEEN
Other - Last Name:WALTERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:3200 N MACARTHUR BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-4453
Mailing Address - Country:US
Mailing Address - Phone:972-258-7979
Mailing Address - Fax:972-570-5502
Practice Address - Street 1:3200 N MACARTHUR BLVD
Practice Address - Street 2:STE 200
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-4453
Practice Address - Country:US
Practice Address - Phone:972-258-7979
Practice Address - Fax:972-570-5502
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX03858T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist