Provider Demographics
NPI:1669628079
Name:WALTERS, THOMAS RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:RICHARD
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 1:130 GREENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041-1447
Mailing Address - Country:US
Mailing Address - Phone:973-379-9618
Mailing Address - Fax:
Practice Address - Street 1:130 GREENWOOD DR
Practice Address - Street 2:
Practice Address - City:MILLBURN
Practice Address - State:NJ
Practice Address - Zip Code:07041-1447
Practice Address - Country:US
Practice Address - Phone:973-379-9618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02664200208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics