Provider Demographics
NPI:1114985231
Name:WALTERS, DAVID J (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:J
Last Name:WALTERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:86067 SHELTER ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-8153
Mailing Address - Country:US
Mailing Address - Phone:904-225-8477
Mailing Address - Fax:912-283-7026
Practice Address - Street 1:1507 ALICE ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-4530
Practice Address - Country:US
Practice Address - Phone:912-283-7220
Practice Address - Fax:912-283-7026
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA043811207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000756313AMedicaid
GA08BDLZQMedicare ID - Type UnspecifiedMEDICARE NUMBER
GA000756313AMedicaid