Provider Demographics
NPI:1922345115
Name:FANBURG, WALTER (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:FANBURG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4413 MUNCASTER MILL RD
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20853-1434
Mailing Address - Country:US
Mailing Address - Phone:240-832-8409
Mailing Address - Fax:301-493-4737
Practice Address - Street 1:4413 MUNCASTER MILL RD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20853-1434
Practice Address - Country:US
Practice Address - Phone:240-832-8409
Practice Address - Fax:301-493-4737
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-09
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00040332084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry