Provider Demographics
NPI:1083653075
Name:RICHTER, WALTER M (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:M
Last Name:RICHTER
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:PO BOX 262
Mailing Address - Street 2:
Mailing Address - City:PROVINCETOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02657-0262
Mailing Address - Country:US
Mailing Address - Phone:508-487-2303
Mailing Address - Fax:
Practice Address - Street 1:3 UPPER MILLER HILL RD
Practice Address - Street 2:
Practice Address - City:PROVINCETOWN
Practice Address - State:MA
Practice Address - Zip Code:02657-1628
Practice Address - Country:US
Practice Address - Phone:508-487-2303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA44126207P00000X
MT10823208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2073986Medicaid
MAL11013OtherBLUE SHIELD
MAL11013OtherBLUE SHIELD
MA2073986Medicaid