Provider Demographics
NPI:1043200280
Name:FLETCHER, WALTER FRIZZELL (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:FRIZZELL
Last Name:FLETCHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1378
Mailing Address - Country:US
Mailing Address - Phone:877-748-7030
Mailing Address - Fax:877-264-9140
Practice Address - Street 1:117 KENNEDY DR
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:TN
Practice Address - Zip Code:38237-3309
Practice Address - Country:US
Practice Address - Phone:731-587-9511
Practice Address - Fax:731-587-0785
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25879207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00034971OtherRAILROAD MEDICARE
TN30848602OtherMEDICARE
TN4173958OtherBLUE CROSS AND BLUE SHIELD
TNJT1036OtherCIGNA
TN30848602Medicaid
TNP00034971OtherRAILROAD MEDICARE