Provider Demographics
NPI:1760060636
Name:TOLLER, WALTER LEWIS III
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:LEWIS
Last Name:TOLLER
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2439 E LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21213-2562
Mailing Address - Country:US
Mailing Address - Phone:410-530-6612
Mailing Address - Fax:
Practice Address - Street 1:2439 E LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21213-2562
Practice Address - Country:US
Practice Address - Phone:410-530-6612
Practice Address - Fax:410-747-4076
Is Sole Proprietor?:No
Enumeration Date:2021-03-31
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR197972363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner