Provider Demographics
NPI:1265063002
Name:WALTERS, PAUL-DOUGLAS
Entity type:Individual
Prefix:
First Name:PAUL-DOUGLAS
Middle Name:
Last Name:WALTERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 RAINTEE CIRCLE, SUITE 130
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013
Mailing Address - Country:US
Mailing Address - Phone:469-363-8552
Mailing Address - Fax:
Practice Address - Street 1:1101 RAINTEE CIRCLE, SUITE 130
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013
Practice Address - Country:US
Practice Address - Phone:469-363-8552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1163539261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy