Provider Demographics
NPI:1699944181
Name:WALTERS, BRANDON R (OD)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:R
Last Name:WALTERS
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 1:1515 E COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:OTHELLO
Mailing Address - State:WA
Mailing Address - Zip Code:99344-1846
Mailing Address - Country:US
Mailing Address - Phone:509-488-5250
Mailing Address - Fax:509-488-9939
Practice Address - Street 1:1051 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:CONNELL
Practice Address - State:WA
Practice Address - Zip Code:99326-8702
Practice Address - Country:US
Practice Address - Phone:509-488-5256
Practice Address - Fax:509-488-9939
Is Sole Proprietor?:No
Enumeration Date:2008-02-28
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6664178-9934152W00000X
WAOD60040766152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2034643Medicaid
WAOD60040766OtherDOH LICENSE