Provider Demographics
NPI:1073797197
Name:GEORGE, WALTER F (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:F
Last Name:GEORGE
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 1:9290 SE SUNNYBROOK BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-6899
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9290 SE SUNNYBROOK BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-6899
Practice Address - Country:US
Practice Address - Phone:503-216-7960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-26
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17036207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR151260Medicaid
OR151260Medicaid