Provider Demographics
NPI:1730132812
Name:WALTERS, RICHARD C (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:C
Last Name:WALTERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9016
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:3915 WATSON RD
Practice Address - Street 2:SUITE 201
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-1251
Practice Address - Country:US
Practice Address - Phone:314-878-5599
Practice Address - Fax:314-833-5833
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR5775207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA10967Medicare UPIN
MO201966421Medicaid
MO13012931Medicare ID - Type Unspecified