Provider Demographics
NPI:1821105859
Name:WALTER, MARY JANE (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:JANE
Last Name:WALTER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 FLORIDA PARK DR
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137
Mailing Address - Country:US
Mailing Address - Phone:386-445-4734
Mailing Address - Fax:386-445-8411
Practice Address - Street 1:11 FLORIDA PARK DR
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137
Practice Address - Country:US
Practice Address - Phone:386-445-4734
Practice Address - Fax:386-445-8411
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO-1735213E00000X, 213EP1101X, 213ES0131X
FLPO1735213ER0200X, 213ES0000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0774230001Medicare NSC
FL87964Medicare PIN
T55623Medicare UPIN