Provider Demographics
NPI:1619948379
Name:WALTER, CORNELIUS TODD (MD)
Entity Type:Individual
Prefix:
First Name:CORNELIUS
Middle Name:TODD
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:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:133 N HOWARD AVE
Practice Address - Street 2:
Practice Address - City:LANDRUM
Practice Address - State:SC
Practice Address - Zip Code:29356
Practice Address - Country:US
Practice Address - Phone:864-560-9507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9601513207Q00000X
SC17420207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC174206Medicaid
SCF876975121OtherMEDICARE PIN
NC890665GMedicaid
NCP00721817OtherRR MEDICARE
NC2279674COtherMEDICARE PIN
SC5850260OtherAETNA
SC080120336OtherRAIL ROAD MEDICARE
SC66392OtherMEDCOST
SCF876975121Medicare PIN
SC174206Medicaid
NC2279674AMedicare PIN