Provider Demographics
NPI:1861675688
Name:GRIFFIN, WALTER JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:JAMES
Last Name:GRIFFIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9111 OLIVE BLVD
Mailing Address - Street 2:APT. 1C
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-3724
Mailing Address - Country:US
Mailing Address - Phone:314-991-2761
Mailing Address - Fax:
Practice Address - Street 1:9111 OLIVE BLVD
Practice Address - Street 2:APT. 1C
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-3724
Practice Address - Country:US
Practice Address - Phone:314-991-2761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-14
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD36607207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203049309Medicaid