Provider Demographics
NPI:1376650481
Name:WOLTERS, WILLIAM C (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:C
Last Name:WOLTERS
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 1000
Mailing Address - Street 2:DEPT 510
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148
Mailing Address - Country:US
Mailing Address - Phone:901-384-8040
Mailing Address - Fax:901-309-8784
Practice Address - Street 1:3173 KIRBY WHITTEN RD
Practice Address - Street 2:STE 104
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38138
Practice Address - Country:US
Practice Address - Phone:901-384-8040
Practice Address - Fax:901-309-8784
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN286222084P0800X
ARE28922084P0800X
MS172152084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3807230Medicaid
3807230Medicare ID - Type Unspecified
TN3807230Medicaid