Provider Demographics
NPI:1104826429
Name:IMMEL, WALTER W (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:W
Last Name:IMMEL
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 1:5510 ALMA LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22151-4012
Mailing Address - Country:US
Mailing Address - Phone:703-642-5990
Mailing Address - Fax:703-642-5003
Practice Address - Street 1:5510 ALMA LN
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22151-4012
Practice Address - Country:US
Practice Address - Phone:703-642-5990
Practice Address - Fax:703-642-5003
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101039106207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4091831OtherAHP MGD CHOICE
VA723556OtherAFFORDABLE FIRST HEALTH
VA51166OtherMDIPA/OPTIMUM CHOICE/MAMS
VA2900048OtherUNITED HEALTH VIRGINIA
VA2006963OtherAETNA/US HEALTHCARE
VA224009OtherHEALTHKEEPERS
VA2900633OtherUNITED HEALTH MID-ATLANTI
VA5819393Medicaid
VA45560002OtherBCBS DC CAPCARE
VA1965376002OtherCIGNA HMO
VA224009OtherTRIGON KEYAD
VA505112OtherNCPPO
VA630385OtherONE HEALTH GREATWEST
VA630385OtherONE HEALTH GREATWEST
VA505112OtherNCPPO