Provider Demographics
NPI:1114241882
Name:WALTERS, BRIAN LEE (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:LEE
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 1:9555 UPLAND LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4485
Mailing Address - Country:US
Mailing Address - Phone:952-806-5600
Mailing Address - Fax:952-993-1453
Practice Address - Street 1:9555 UPLAND LN N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369
Practice Address - Country:US
Practice Address - Phone:952-806-5600
Practice Address - Fax:952-993-1453
Is Sole Proprietor?:No
Enumeration Date:2010-03-24
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN60003207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine