Provider Demographics
NPI:1750460317
Name:WALTHALL, WALTER (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:WALTHALL
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 1:3338 OAKWELL COURT
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78218-3019
Mailing Address - Country:US
Mailing Address - Phone:210-822-3646
Mailing Address - Fax:210-822-5242
Practice Address - Street 1:3338 OAKWELL COURT
Practice Address - Street 2:SUITE 107
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78218-3019
Practice Address - Country:US
Practice Address - Phone:210-822-3646
Practice Address - Fax:210-822-5242
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0956207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
8055B0Medicare ID - Type Unspecified
H31613Medicare UPIN