Provider Demographics
NPI:1619939543
Name:WALTER, MARK EUGENE (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EUGENE
Last Name:WALTER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3877 HIGHPOINT DR
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-6142
Mailing Address - Country:US
Mailing Address - Phone:610-554-8290
Mailing Address - Fax:
Practice Address - Street 1:1124 GLENLIVET DR
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18106-3104
Practice Address - Country:US
Practice Address - Phone:610-554-8290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC006644L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0796190Medicaid
PA529404Medicare ID - Type Unspecified
PAU63731Medicare UPIN