Provider Demographics
NPI:1114952074
Name:WALTERS, FREDERICK P (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:P
Last Name:WALTERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:12345 W BEND DR
Mailing Address - Street 2:SUITE200
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2104
Mailing Address - Country:US
Mailing Address - Phone:314-843-8000
Mailing Address - Fax:314-843-3004
Practice Address - Street 1:12345 W BEND DR
Practice Address - Street 2:SUITE200
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2104
Practice Address - Country:US
Practice Address - Phone:314-843-8000
Practice Address - Fax:314-843-3004
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR1J55208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO005010433Medicare ID - Type Unspecified
MOF50659Medicare UPIN