Provider Demographics
NPI:1093865883
Name:WALTS, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WALTS
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 642117
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-8117
Mailing Address - Country:US
Mailing Address - Phone:402-717-4377
Mailing Address - Fax:
Practice Address - Street 1:1414 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PAPILLION
Practice Address - State:NE
Practice Address - Zip Code:68046-4163
Practice Address - Country:US
Practice Address - Phone:402-827-4992
Practice Address - Fax:402-827-4975
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE17763207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
270658Medicare ID - Type Unspecified
G47344Medicare UPIN