Provider Demographics
NPI:1104827120
Name:LOVE, WALTER KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:KENNETH
Last Name:LOVE
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 309
Mailing Address - Street 2:
Mailing Address - City:WALDOBORO
Mailing Address - State:ME
Mailing Address - Zip Code:04572
Mailing Address - Country:US
Mailing Address - Phone:207-832-5813
Mailing Address - Fax:207-832-3070
Practice Address - Street 1:1034 MAIN ST
Practice Address - Street 2:
Practice Address - City:WALDOBORO
Practice Address - State:ME
Practice Address - Zip Code:04572-6037
Practice Address - Country:US
Practice Address - Phone:207-832-5813
Practice Address - Fax:207-832-3070
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME012987207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME308080099Medicaid
ME100367OtherANTHEM
ME1396848297OtherGROUP NPI #
ME043833726OtherTAX ID #
ME1396848297OtherGROUP NPI #
ME308080099Medicaid