Provider Demographics
NPI:1386774800
Name:WALTS, KRISTINA FREEMAN (OD)
Entity type:Individual
Prefix:DR
First Name:KRISTINA
Middle Name:FREEMAN
Last Name:WALTS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 WIEUCA TRCE NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-3856
Mailing Address - Country:US
Mailing Address - Phone:404-252-6250
Mailing Address - Fax:
Practice Address - Street 1:35 WIEUCA TRCE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-3856
Practice Address - Country:US
Practice Address - Phone:404-252-6250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT 001212152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGA2212OtherEYEMED
GAU27728Medicare UPIN
GA41ZCBWTMedicare ID - Type Unspecified