Basic Information
| Provider Information | |||||||||
| NPI: | 1154478329 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLER | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 608 STANTON L YOUNG BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731045014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052716060 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 608 STANTON L YOUNG BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731045014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052716060 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 23523 | OK | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.