Provider Demographics
NPI:1851328025
Name:MINAERT, WALTER AUGUST JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:AUGUST
Last Name:MINAERT
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:21017 STATE ROUTE 12F
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-1078
Mailing Address - Country:US
Mailing Address - Phone:315-782-1990
Mailing Address - Fax:315-782-1037
Practice Address - Street 1:21017 STATE ROUTE 12F
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-1078
Practice Address - Country:US
Practice Address - Phone:315-782-1990
Practice Address - Fax:315-782-1037
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1227821208600000X
NY122792208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00585011Medicaid
AM7456379OtherDEA
NY00585011Medicaid
AM7456379OtherDEA
NYJ400000972Medicare PIN