Provider Demographics
NPI:1861502361
Name:WALTER, BROOKE KAIULANI (MD)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:KAIULANI
Last Name:WALTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:KAULANI
Other - Last Name:GERTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:847 NE 19TH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2684
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:1600 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1426
Practice Address - Country:US
Practice Address - Phone:503-963-3100
Practice Address - Fax:503-459-5398
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD 600014432084N0400X
ORMD1513872084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500628436Medicaid
WA1089540Medicaid
WA1089540Medicaid