Provider Demographics
NPI:1245254028
Name:WALTER, HEIDI MARA (MD)
Entity type:Individual
Prefix:DR
First Name:HEIDI
Middle Name:MARA
Last Name:WALTER
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 1:1405 CHAMBOLLE CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89144-1136
Mailing Address - Country:US
Mailing Address - Phone:702-341-9465
Mailing Address - Fax:866-804-7676
Practice Address - Street 1:1405 CHAMBOLLE CT
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144-1136
Practice Address - Country:US
Practice Address - Phone:702-341-9465
Practice Address - Fax:866-804-7676
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11600207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08732787Medicaid
NV11600OtherNV STATE MEDICAL LICENSE
NV11600OtherNV STATE MEDICAL LICENSE
NVBW6679596OtherFEDERAL DEA NUMBER
COH93069Medicare UPIN