Provider Demographics
NPI:1083628648
Name:WALTERS, KERMIT L JR (MD)
Entity Type:Individual
Prefix:
First Name:KERMIT
Middle Name:L
Last Name:WALTERS
Suffix:JR
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 1:1910 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71202-2532
Mailing Address - Country:US
Mailing Address - Phone:318-325-7998
Mailing Address - Fax:318-398-0888
Practice Address - Street 1:1910 JACKSON ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71202-2532
Practice Address - Country:US
Practice Address - Phone:318-325-7998
Practice Address - Fax:318-398-0888
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12847207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1313220Medicaid
B60629Medicare UPIN
LA1313220Medicaid