Provider Demographics
NPI:1780671909
Name:PEDERSEN, WALTER JM JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:JM
Last Name:PEDERSEN
Suffix:JR
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:PO BOX 7840
Mailing Address - Street 2:SUNNY ISLE PROFESSIONAL BLDG, STE 3
Mailing Address - City:ST CROIX
Mailing Address - State:VI
Mailing Address - Zip Code:00823-7840
Mailing Address - Country:US
Mailing Address - Phone:340-778-6110
Mailing Address - Fax:340-778-2919
Practice Address - Street 1:SUNNY ISLE PROFESSIONAL BUILDING
Practice Address - Street 2:SUITE 3-F
Practice Address - City:ST. CROIX
Practice Address - State:VI
Practice Address - Zip Code:00820-4423
Practice Address - Country:US
Practice Address - Phone:340-778-6110
Practice Address - Fax:340-778-2919
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VI653174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VIV1000011OtherTRICARE
VI1780671909OtherNPI
VI53699PEOtherTRIPLE S
VI089045OtherBLUE CROSS BLUE SHIELD VI
VI0500138OtherHUMANA
VIV1000011OtherTRICARE
VI0024441Medicare PIN