Provider Demographics
NPI:1548225410
Name:KECKICH, WALTER (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:
Last Name:KECKICH
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 1:1606 PHYSICIANS DR
Mailing Address - Street 2:VA CLINIC OF WILMINGTON
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7348
Mailing Address - Country:US
Mailing Address - Phone:910-362-8811
Mailing Address - Fax:910-362-8881
Practice Address - Street 1:1606 PHYSICIANS DR
Practice Address - Street 2:VA CLINIC OF WILMINGTON
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7348
Practice Address - Country:US
Practice Address - Phone:910-362-8811
Practice Address - Fax:910-362-8881
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
D83563Medicare UPIN