Provider Demographics
NPI:1518925072
Name:FRIEDLEY, WALTER JONATHAN (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:JONATHAN
Last Name:FRIEDLEY
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:L-3549
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43260-0001
Mailing Address - Country:US
Mailing Address - Phone:740-383-7927
Mailing Address - Fax:740-383-7942
Practice Address - Street 1:1040 DELAWARE AVENEUE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43301-1814
Practice Address - Country:US
Practice Address - Phone:740-383-8090
Practice Address - Fax:740-375-6481
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.079367208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2244360Medicaid
311098079OtherTAX ID
1202702OtherUHC
7052274OtherAETNA
353077OtherSUBMITTER NO
000000202163OtherANTHEM
311090079OtherCIGNA
370018677OtherTRAVELERS MEDICARE
311090079OtherCIGNA
353077OtherSUBMITTER NO