Provider Demographics
NPI:1588732846
Name:ROSEN, WALTER M (OD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:M
Last Name:ROSEN
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 1:3103 FM 1960 RD W
Mailing Address - Street 2:SUITE V
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77338-3371
Mailing Address - Country:US
Mailing Address - Phone:281-443-0340
Mailing Address - Fax:281-443-0350
Practice Address - Street 1:3103 FM 1960 RD W
Practice Address - Street 2:SUITE V
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338-3371
Practice Address - Country:US
Practice Address - Phone:281-443-0340
Practice Address - Fax:281-443-0350
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1827TG152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX93202201Medicaid
TXT15633Medicare UPIN
TX93202201Medicaid