Provider Demographics
NPI:1316017429
Name:NULL, WALTER B (DC)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:B
Last Name:NULL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4867 MUNSON ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718
Mailing Address - Country:US
Mailing Address - Phone:330-494-5533
Mailing Address - Fax:330-494-8101
Practice Address - Street 1:4867 MUNSON ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718
Practice Address - Country:US
Practice Address - Phone:330-494-5533
Practice Address - Fax:330-494-8101
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3073111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0186025Medicaid
NU4099091Medicare ID - Type Unspecified
U93504Medicare UPIN