Provider Demographics
NPI:1457317190
Name:WALTER, THOMAS H (DPM)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:H
Last Name:WALTER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:PAWCATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06379-1538
Mailing Address - Country:US
Mailing Address - Phone:860-599-4555
Mailing Address - Fax:860-599-1394
Practice Address - Street 1:145 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:PAWCATUCK
Practice Address - State:CT
Practice Address - Zip Code:06379-1538
Practice Address - Country:US
Practice Address - Phone:860-599-4555
Practice Address - Fax:860-599-1394
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTP00337213E00000X
RIDPM00211213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4061347Medicaid
CT059393001OtherDMERC
CT480000279Medicare ID - Type Unspecified
CT4061347Medicaid