Provider Demographics
NPI:1386640175
Name:WALTER, MATTHEW TIMOTHY (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:TIMOTHY
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 1:13181 RIDGELINE RD
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-9190
Mailing Address - Country:US
Mailing Address - Phone:479-273-5766
Mailing Address - Fax:479-273-5766
Practice Address - Street 1:225 N BLOOMINGTON ST
Practice Address - Street 2:SUITES B-D
Practice Address - City:LOWELL
Practice Address - State:AR
Practice Address - Zip Code:72745-9103
Practice Address - Country:US
Practice Address - Phone:479-757-5054
Practice Address - Fax:479-757-5055
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-26
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015019923207P00000X
ARE-0008207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR129927001Medicaid
AR129927001Medicaid
AR5J957Medicare ID - Type Unspecified