Provider Demographics
NPI:1285629808
Name:WALTHER, JASON MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:MICHAEL
Last Name:WALTHER
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 1:200 BANNING ST
Mailing Address - Street 2:SUITE 250
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904
Mailing Address - Country:US
Mailing Address - Phone:302-736-1320
Mailing Address - Fax:302-736-0769
Practice Address - Street 1:200 BANNING ST
Practice Address - Street 2:SUITE 250
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904
Practice Address - Country:US
Practice Address - Phone:302-736-1320
Practice Address - Fax:302-736-0769
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DECI0002871208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE000059801Medicaid
DE000059801Medicaid
DE145312Medicare ID - Type Unspecified