Provider Demographics
NPI:1114122405
Name:WALTERS, DUSTIN M (MD)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:M
Last Name:WALTERS
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 1:263 FARMINGTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-8063
Mailing Address - Country:US
Mailing Address - Phone:860-679-8080
Mailing Address - Fax:860-667-9143
Practice Address - Street 1:263 FARMINGTON AVENUE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-8063
Practice Address - Country:US
Practice Address - Phone:860-679-8080
Practice Address - Fax:860-667-9143
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101256181208G00000X
VA0116019584390200000X
CT076337208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program