Provider Demographics
NPI:1245230655
Name:WALTHER, JAY R (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:R
Last Name:WALTHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JAY
Other - Middle Name:R
Other - Last Name:WALTHER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:628 N ED CAREY DR
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550-7912
Mailing Address - Country:US
Mailing Address - Phone:956-423-1121
Mailing Address - Fax:956-423-1202
Practice Address - Street 1:628 N ED CAREY DR
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-7912
Practice Address - Country:US
Practice Address - Phone:956-423-1121
Practice Address - Fax:956-423-1202
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG2301207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX128587602Medicaid
TX128587602Medicaid
TXD12958Medicare UPIN