Provider Demographics
NPI:1457330417
Name:WALTER, ANDREA JEANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:JEANNE
Last Name:WALTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:113 MERRITT DR
Mailing Address - Street 2:
Mailing Address - City:ORADELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07649-1822
Mailing Address - Country:US
Mailing Address - Phone:917-855-2511
Mailing Address - Fax:
Practice Address - Street 1:1 PROSPECT ST STE 5
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-4440
Practice Address - Country:US
Practice Address - Phone:551-278-8099
Practice Address - Fax:551-278-8044
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2101612084P0800X
NY2292712084P0800X
NJ25MA089943002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI01522Medicare UPIN
NY589Z51Medicare PIN