Provider Demographics
NPI:1174503981
Name:WALTERS, HENRY LANE III (MD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:LANE
Last Name:WALTERS
Suffix:III
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:PO BOX 441097
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48244-1097
Mailing Address - Country:US
Mailing Address - Phone:313-745-6896
Mailing Address - Fax:313-993-0531
Practice Address - Street 1:3901 BEAUBIEN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2119
Practice Address - Country:US
Practice Address - Phone:313-745-5538
Practice Address - Fax:313-993-0531
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301059126208600000X
MI430105916208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI286376510Medicaid
MI0208211331OtherBCBS
E85773Medicare UPIN
M52440002Medicare ID - Type Unspecified
MI0208211331OtherBCBS