Provider Demographics
NPI:1336119817
Name:WALTERS, SAMUEL (DO)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
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 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:7451 103RD ST STE 8
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-6788
Practice Address - Country:US
Practice Address - Phone:904-683-4968
Practice Address - Fax:904-902-1202
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8337207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261008600Medicaid
58705YMedicare PIN
FLH04251Medicare PIN