Provider Demographics
NPI:1013219435
Name:JOLLY, WALTER WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:WILLIAM
Last Name:JOLLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:10101 DITCH RD
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-8897
Mailing Address - Country:US
Mailing Address - Phone:317-574-0884
Mailing Address - Fax:317-574-0886
Practice Address - Street 1:10101 DITCH RD
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-8897
Practice Address - Country:US
Practice Address - Phone:317-574-0884
Practice Address - Fax:317-574-0886
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-18
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01020461A208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)