Provider Demographics
NPI:1518177500
Name:ASTORNE, WALTER JORGE (MD, FACP)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:JORGE
Last Name:ASTORNE
Suffix:
Gender:M
Credentials:MD, FACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WHITCHER ST NE STE 160
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1160
Mailing Address - Country:US
Mailing Address - Phone:770-422-1372
Mailing Address - Fax:
Practice Address - Street 1:55 WHITCHER ST NE STE 160
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1160
Practice Address - Country:US
Practice Address - Phone:770-422-1372
Practice Address - Fax:770-423-9651
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085400207R00000X
MN52149207RC0200X, 207RN0300X
MN104428207RN0300X
GA081562207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MNENROLLEDMedicaid