Provider Demographics
NPI:1326014770
Name:WALTER, KEVIN A (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:A
Last Name:WALTER
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 1:601 ELMWOOD AVE
Mailing Address - Street 2:BOX 670
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-276-3581
Mailing Address - Fax:585-276-2892
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-0002
Practice Address - Country:US
Practice Address - Phone:585-276-3581
Practice Address - Fax:585-276-2892
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD418563174400000X
NY242379207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02311324Medicaid
RB3068Medicare PIN
PAH33224Medicare UPIN
NY02311324Medicaid