Provider Demographics
NPI:1932118643
Name:WALTERS, ROBERT G (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:G
Last Name:WALTERS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 WALNUT COMMONS LN STE A
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-6037
Mailing Address - Country:US
Mailing Address - Phone:931-528-1331
Mailing Address - Fax:931-528-6893
Practice Address - Street 1:120 WALNUT COMMONS LN STE A
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-6037
Practice Address - Country:US
Practice Address - Phone:931-528-1331
Practice Address - Fax:315-286-8939
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN834213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1932118643 1Medicaid
TNQ037426Medicaid
IL480035000OtherRAILROAD MEDICARE
IL909010OtherMEDICARE GROUP
ILU86305Medicare UPIN
IL1932118643 1Medicaid