Provider Demographics
NPI:1114125739
Name:WALTERS, TRICIA A (MD)
Entity Type:Individual
Prefix:MRS
First Name:TRICIA
Middle Name:A
Last Name:WALTERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:TRICIA
Other - Middle Name:A
Other - Last Name:KURTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:574-647-2129
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:1815 E IRELAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2845
Practice Address - Country:US
Practice Address - Phone:574-647-1750
Practice Address - Fax:574-647-1748
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01065500A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200928780AMedicaid
IN169380065OtherMEDICARE PTAN
IN236040229OtherMEDICARE PTAN
IN11013720AOtherMEDICAL RESIDENCY PERMIT
IN169380065OtherMEDICARE PTAN