Provider Demographics
NPI:1265427645
Name:KOLMODIN, WALTER DOUGLAS (DPM)
Entity type:Individual
Prefix:MR
First Name:WALTER
Middle Name:DOUGLAS
Last Name:KOLMODIN
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 1:14950 STATE ROAD 23
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-7564
Mailing Address - Country:US
Mailing Address - Phone:574-259-9668
Mailing Address - Fax:574-259-9671
Practice Address - Street 1:14950 STATE ROAD 23
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-7564
Practice Address - Country:US
Practice Address - Phone:574-259-9668
Practice Address - Fax:574-259-9671
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000902A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000262667OtherBLUE CROSS BLUE SHIELD
U83500Medicare UPIN
IN000000262667OtherBLUE CROSS BLUE SHIELD