Provider Demographics
NPI:1417993957
Name:COSTNER, WALTER WOOLFOLK (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:WOOLFOLK
Last Name:COSTNER
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 1:2820 E ROCK HAVEN ROAD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:HARRISONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64701
Mailing Address - Country:US
Mailing Address - Phone:816-380-2446
Mailing Address - Fax:816-380-4791
Practice Address - Street 1:2820 E ROCK HAVEN ROAD
Practice Address - Street 2:SUITE 210
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701
Practice Address - Country:US
Practice Address - Phone:816-380-2446
Practice Address - Fax:816-380-4791
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010007567208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery