Provider Demographics
NPI:1639105265
Name:KONSTANZER, WALTER (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:
Last Name:KONSTANZER
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 9021
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92038-9021
Mailing Address - Country:US
Mailing Address - Phone:619-223-2161
Mailing Address - Fax:
Practice Address - Street 1:6690 CAMINITO HERMITAGE
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-5812
Practice Address - Country:US
Practice Address - Phone:619-223-2161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC27500208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA33388Medicare UPIN
CAC27500Medicare ID - Type Unspecified