Individual
MAUREEN KIMORA WALLEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
OD
Contact information
Practice address
5700 WEST GENESEE STREET, SUITE 112, CAMILLUS, NY 13031
(315) 488-1601
(315) 488-0047
Mailing address
5700 WEST GENESEE STREET, SUITE 112, CAMILLUS, NY 13031
(315) 488-1601
(315) 488-0047
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
TUV006882
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
02845334
—
NY
01
—
P00799448
MEDICARE RAILROAD
—
Enumeration date
12/01/2005
Last updated
04/01/2010
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