Provider Demographics
NPI:1528467800
Name:JOSEPH WALD OD INC
Entity type:Organization
Organization Name:JOSEPH WALD OD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FRONT OFFICE/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:APRIL
Authorized Official - Middle Name:
Authorized Official - Last Name:PELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-755-9211
Mailing Address - Street 1:406 E FAIRHAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98233-1819
Mailing Address - Country:US
Mailing Address - Phone:360-755-9211
Mailing Address - Fax:
Practice Address - Street 1:406 E FAIRHAVEN AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98233-1819
Practice Address - Country:US
Practice Address - Phone:360-755-9211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAU27352Medicare UPIN