Provider Demographics
NPI:1376746651
Name:FIFE, WALTER D (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:D
Last Name:FIFE
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 1:954 BARTON CT
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-0906
Mailing Address - Country:US
Mailing Address - Phone:801-683-8003
Mailing Address - Fax:
Practice Address - Street 1:954 BARTON CT
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-0906
Practice Address - Country:US
Practice Address - Phone:801-683-8003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00013702202C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical Examiner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1262807Medicaid
WA001051008Medicare ID - Type UnspecifiedPIERCE COUNTY
WAF00053Medicare UPIN