Provider Demographics
NPI:1720388580
Name:JANE WALTER D.P.M., P.A.
Entity Type:Organization
Organization Name:JANE WALTER D.P.M., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:386-445-4734
Mailing Address - Street 1:11 FLORIDA PARK DR N
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-3866
Mailing Address - Country:US
Mailing Address - Phone:386-445-4734
Mailing Address - Fax:386-445-8411
Practice Address - Street 1:11 FLORIDA PARK DR N
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-3866
Practice Address - Country:US
Practice Address - Phone:386-445-4734
Practice Address - Fax:386-445-8411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-27
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1735261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0774230001Medicare NSC
FLFQ452AMedicare PIN