Provider Demographics
NPI:1659429793
Name:WALTERS, FREDERICK CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:CHARLES
Last Name:WALTERS
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 1:1298 GROW AVE NW
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110
Mailing Address - Country:US
Mailing Address - Phone:206-780-5437
Mailing Address - Fax:206-780-5438
Practice Address - Street 1:1298 GROW AVE NW
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110
Practice Address - Country:US
Practice Address - Phone:206-780-5437
Practice Address - Fax:206-780-5438
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00040201208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7675WAOtherBLUE SHIELD #
WA0039577OtherLABOR AND INDUSTRIES #
WAUS7740466OtherAETNA SPECIALIST PIN
WA8369928Medicaid
H64510Medicare UPIN
WA0039577OtherLABOR AND INDUSTRIES #