Provider Demographics
NPI:1063492064
Name:WALTER, LONNY G (MD)
Entity Type:Individual
Prefix:
First Name:LONNY
Middle Name:G
Last Name:WALTER
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 1:400 INTERNATIONAL DR.
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221
Mailing Address - Country:US
Mailing Address - Phone:716-631-3555
Mailing Address - Fax:716-631-9525
Practice Address - Street 1:400 INTERNATIONAL DR.
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221
Practice Address - Country:US
Practice Address - Phone:716-631-3555
Practice Address - Fax:716-631-9525
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY134833207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0109758OtherIHA
NY00010185703OtherUNIVERA
NY000508199005OtherBC/BS
NY00753851Medicaid
NY00010185703OtherUNIVERA
NY00753851Medicaid