Provider Demographics
NPI:1073735403
Name:WALTER, MARC STUART (PHD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:STUART
Last Name:WALTER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7220 N 16TH ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-5253
Mailing Address - Country:US
Mailing Address - Phone:602-944-0480
Mailing Address - Fax:602-944-1078
Practice Address - Street 1:7220 N 16TH ST
Practice Address - Street 2:SUITE G
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-5253
Practice Address - Country:US
Practice Address - Phone:602-944-0480
Practice Address - Fax:602-944-1078
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ856103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R03081Medicare UPIN
107743Medicare PIN