Provider Demographics
NPI:1407849060
Name:BIRKENHAGEN, WALTER KURT (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:KURT
Last Name:BIRKENHAGEN
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 1:500 S 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4835
Mailing Address - Country:US
Mailing Address - Phone:208-232-7434
Mailing Address - Fax:208-233-6446
Practice Address - Street 1:500 S 11TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4835
Practice Address - Country:US
Practice Address - Phone:208-232-7434
Practice Address - Fax:208-233-6446
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3705208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002370100Medicaid
ID002370100Medicaid
ID1111909Medicare ID - Type Unspecified