Provider Demographics
NPI:1497716211
Name:FASOLAK, WALTER S (DO)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:S
Last Name:FASOLAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 749
Mailing Address - Street 2:SOUTHERN PINES WOMENS HEALTH CENTER PC
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28388-0749
Mailing Address - Country:US
Mailing Address - Phone:910-692-7928
Mailing Address - Fax:910-692-5962
Practice Address - Street 1:145 APPLECROSS RD
Practice Address - Street 2:SOUTHERN PINES WOMENS HEALTH CENTER PC
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387
Practice Address - Country:US
Practice Address - Phone:910-692-7928
Practice Address - Fax:910-692-5962
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC39728207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8931369Medicaid
SCQ39728Medicaid
31369OtherBLUE CROSS BLUE SHIELD
9663436OtherGHI
980000066OtherMEDICARE RAILROAD
FH1000115OtherFIRST CAROLINA CARE
42653OtherMEDCOST
31369OtherBLUE CROSS BLUE SHIELD
FH1000115OtherFIRST CAROLINA CARE