Provider Demographics
NPI:1255313789
Name:WALTERS, GORDON LESLIE (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:LESLIE
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:PO BOX 925
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30903-0925
Mailing Address - Country:US
Mailing Address - Phone:706-724-3473
Mailing Address - Fax:706-724-3493
Practice Address - Street 1:818 SAINT SEBASTIAN WAY
Practice Address - Street 2:SUITE 311
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2651
Practice Address - Country:US
Practice Address - Phone:706-724-3473
Practice Address - Fax:706-724-3493
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030919207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA024281OtherBCBS
SCG30919Medicaid
GA000385602AMedicaid