Provider Demographics
NPI:1629034475
Name:WALTERS, MICHAEL A (PT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:A
Last Name:WALTERS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1439 SWAN LN
Mailing Address - Street 2:
Mailing Address - City:MULLICA HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08062-3246
Mailing Address - Country:US
Mailing Address - Phone:856-223-8898
Mailing Address - Fax:856-223-8799
Practice Address - Street 1:1439 SWAN LN
Practice Address - Street 2:
Practice Address - City:MULLICA HILL
Practice Address - State:NJ
Practice Address - Zip Code:08062-3246
Practice Address - Country:US
Practice Address - Phone:856-223-8898
Practice Address - Fax:856-223-8799
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00576300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0710194000OtherAMERIHEALTH
NJ025701Medicare ID - Type Unspecified