Provider Demographics
NPI:1063679553
Name:WALTERS, JASON ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:ANTHONY
Last Name:WALTERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1700 NW 49TH ST STE 125
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3750
Mailing Address - Country:US
Mailing Address - Phone:954-522-3355
Mailing Address - Fax:954-522-9590
Practice Address - Street 1:1601 S ANDREWS AVE FL 2
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2509
Practice Address - Country:US
Practice Address - Phone:954-522-3355
Practice Address - Fax:954-522-9590
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP7722207XX0005X
FLME117228207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018508700Medicaid