Provider Demographics
NPI:1528069234
Name:WALKER, KEVIN ROGER (OD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:ROGER
Last Name:WALKER
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:PO BOX 207261
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7261
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:
Practice Address - Street 1:215 MOORE RD
Practice Address - Street 2:
Practice Address - City:KING
Practice Address - State:NC
Practice Address - Zip Code:27021-8703
Practice Address - Country:US
Practice Address - Phone:336-985-2020
Practice Address - Fax:336-985-2133
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2020-06-02
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-04-11
Provider Licenses
StateLicense IDTaxonomies
NC1560152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC410041919OtherRAILROAD MEDICARE
NC093GROtherBCBS PROV #
NC7909939Medicaid
NC268250OtherANTHEM BCBS-KING PROV #
NC268250OtherANTHEM BCBS-KING PROV #
NC093GROtherBCBS PROV #