Provider Demographics
NPI:1629118906
Name:RICHARD L. WALTER, M.D., A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:RICHARD L. WALTER, M.D., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MISS
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-908-8048
Mailing Address - Street 1:18375 VENTURA BLVD
Mailing Address - Street 2:SUITE 614
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-4218
Mailing Address - Country:US
Mailing Address - Phone:818-908-8048
Mailing Address - Fax:818-908-8072
Practice Address - Street 1:5525 ETIWANDA AVE
Practice Address - Street 2:SUITE 318
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3647
Practice Address - Country:US
Practice Address - Phone:818-528-1270
Practice Address - Fax:818-528-1275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG31570207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW21282Medicare PIN