Provider Demographics
NPI:1366511388
Name:WALTER, DARRELL RAY (OD)
Entity type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:RAY
Last Name:WALTER
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 1:107 KINGSWAY RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33510-4601
Mailing Address - Country:US
Mailing Address - Phone:813-689-2222
Mailing Address - Fax:813-689-0802
Practice Address - Street 1:107 KINGSWAY RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510-4601
Practice Address - Country:US
Practice Address - Phone:813-689-2222
Practice Address - Fax:813-689-0802
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1125152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19792OtherBLUE CROSS BLUE SHIELD
19792Medicare PIN
0499170001Medicare NSC
T84045Medicare UPIN