Provider Demographics
NPI:1366679458
Name:WALTERS, KENNETH CHET (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:CHET
Last Name:WALTERS
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:PO BOX 100174
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-3174
Mailing Address - Country:US
Mailing Address - Phone:864-512-5667
Mailing Address - Fax:864-512-6746
Practice Address - Street 1:2000 E GREENVILLE ST STE 1100
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-1714
Practice Address - Country:US
Practice Address - Phone:864-512-5667
Practice Address - Fax:864-512-6746
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-16
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11014996A390200000X
SC34958207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003166327AMedicaid
SC349581Medicaid
SC349581Medicaid