Provider Demographics
NPI:1639196454
Name:COOMBE, WALTER THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:THOMAS
Last Name:COOMBE
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 3409
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85547-3409
Mailing Address - Country:US
Mailing Address - Phone:928-468-9280
Mailing Address - Fax:928-468-9280
Practice Address - Street 1:116 S ELMER AVE
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-2006
Practice Address - Country:US
Practice Address - Phone:570-887-2849
Practice Address - Fax:570-887-2244
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9048207Y00000X
AZ36942207Y00000X
PAMD459747207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ218514Medicaid
A85890Medicare UPIN
AZ115806Medicare PIN