Provider Demographics
NPI:1639146780
Name:FANNING, WALTER LEE JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:LEE
Last Name:FANNING
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:200 MEDICAL ARTS DRIVE
Mailing Address - Street 2:SUITE 280 CAROLINAS MEDICAL CENTER NORTH EAST
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-0935
Mailing Address - Country:US
Mailing Address - Phone:704-403-1766
Mailing Address - Fax:704-403-1096
Practice Address - Street 1:200 MEDICAL PARK DR STE 280
Practice Address - Street 2:CAROLINAS MEDICAL CENTER NORTH EAST
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-0935
Practice Address - Country:US
Practice Address - Phone:704-403-1766
Practice Address - Fax:704-403-1096
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2010-07-13
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Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC2006-00672207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1527547OtherCIGNA
NC00339806OtherRAILROAD MEDICARE
NC142K2OtherBCBSNC
NC2055819AOtherMEDICARE PTAN, INDIVIDUAL
NC190800OtherMEDCOST
NC808032OtherPARTNERS MEDICARE CHOICE
NC4302912OtherAETNA
NC232009OtherMEDICARE PTAN, GROUP
NC5903747Medicaid
NC142K2OtherBCBSNC