Provider Demographics
NPI:1538131107
Name:WALTER, BRADLEY N (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:N
Last Name:WALTER
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 1:3334 CAPITAL MEDICAL BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4470
Mailing Address - Country:US
Mailing Address - Phone:229-226-3060
Mailing Address - Fax:855-460-8658
Practice Address - Street 1:113 W HANSELL ST
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6664
Practice Address - Country:US
Practice Address - Phone:229-226-3060
Practice Address - Fax:855-460-8658
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME109799207X00000X
GAGA047550207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000832367BOtherPEACH STATE
GA000832367BMedicaid
GA200037739OtherRAIL ROAD MEDICARE
GA344404OtherWELLCARE
GA20BBDZWMedicare PIN
GA200037739OtherRAIL ROAD MEDICARE