Provider Demographics
NPI:1891883666
Name:WALTERS, TERRY JANE (MD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:JANE
Last Name:WALTERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 BLACK MOUNTAIN LN
Mailing Address - Street 2:
Mailing Address - City:AU SABLE FORKS
Mailing Address - State:NY
Mailing Address - Zip Code:12912-4722
Mailing Address - Country:US
Mailing Address - Phone:301-646-2903
Mailing Address - Fax:
Practice Address - Street 1:102 BLACK MOUNTAIN LN
Practice Address - Street 2:
Practice Address - City:AU SABLE FORKS
Practice Address - State:NY
Practice Address - Zip Code:12912-4722
Practice Address - Country:US
Practice Address - Phone:301-646-2903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY281388207R00000X
WAMD00024597207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine