Provider Demographics
NPI:1326003757
Name:WALTER, EARL THOMAS (DO)
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:THOMAS
Last Name:WALTER
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:PO BOX 764
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-0764
Mailing Address - Country:US
Mailing Address - Phone:620-365-6933
Mailing Address - Fax:620-365-8126
Practice Address - Street 1:401 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:IOLA
Practice Address - State:KS
Practice Address - Zip Code:66749-3256
Practice Address - Country:US
Practice Address - Phone:620-365-6933
Practice Address - Fax:620-365-8126
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-16916207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100098460 BMedicaid
KS100098460 BMedicaid
045133Medicare Oscar/Certification