Provider Demographics
NPI:1609885748
Name:WALTERS, DAVID P (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:P
Last Name:WALTERS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 634087
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-1744
Mailing Address - Country:US
Mailing Address - Phone:800-540-8739
Mailing Address - Fax:616-975-9827
Practice Address - Street 1:28050 GRAND RIVER AVE
Practice Address - Street 2:ER DEPARTMENT
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336
Practice Address - Country:US
Practice Address - Phone:248-471-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDW009999207PE0004X
MI5101009999207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114570833Medicaid
F00491Medicare UPIN