Provider Demographics
NPI:1427014794
Name:WALTERS, RANDALL WAYNE (MD)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:WAYNE
Last Name:WALTERS
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 1680
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25717-1680
Mailing Address - Country:US
Mailing Address - Phone:304-697-1396
Mailing Address - Fax:304-697-2086
Practice Address - Street 1:22 FLEMING DR
Practice Address - Street 2:
Practice Address - City:HARTS
Practice Address - State:WV
Practice Address - Zip Code:25524-9788
Practice Address - Country:US
Practice Address - Phone:304-855-4595
Practice Address - Fax:304-855-9377
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22354207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP01128276OtherMEDICARE RR PTAN
WV3810005193Medicaid
WVWV2707C437Medicare PIN
WVWV2707C604Medicare PIN
WV2027413Medicare PIN
WV3810005193Medicaid
WVWV2707CMedicare PIN
WVWV2707C196Medicare PIN
WVWV2707C729Medicare PIN
WVWV2707C830Medicare PIN
WVP01128276OtherMEDICARE RR PTAN
WVWA2027411Medicare PIN
WVWV2707BMedicare PIN
WVWV2707EMedicare PIN
WVWV2707Medicare PIN
WV2027415Medicare PIN
WVWV2707DMedicare PIN
WVWV2707C197Medicare PIN
WV2027414Medicare PIN
WV2027412Medicare PIN