Provider Demographics
NPI:1306827076
Name:WALTERS, DAVID L (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:WALTERS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FOWLER
Mailing Address - State:CO
Mailing Address - Zip Code:81039-1132
Mailing Address - Country:US
Mailing Address - Phone:719-263-5005
Mailing Address - Fax:719-263-5485
Practice Address - Street 1:217 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FOWLER
Practice Address - State:CO
Practice Address - Zip Code:81039-1132
Practice Address - Country:US
Practice Address - Phone:719-263-5005
Practice Address - Fax:719-263-5485
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39179208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO516538Medicare ID - Type Unspecified
COH20448Medicare UPIN