Provider Demographics
NPI:1336367234
Name:JOE WALTERS MD INC. A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:JOE WALTERS MD INC. A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-253-4806
Mailing Address - Street 1:12961 VILLAGE DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SARATOGA
Mailing Address - State:CA
Mailing Address - Zip Code:95070-4158
Mailing Address - Country:US
Mailing Address - Phone:408-253-4806
Mailing Address - Fax:408-257-9701
Practice Address - Street 1:12961 VILLAGE DRIVE
Practice Address - Street 2:SUITE 1
Practice Address - City:SARATOGA
Practice Address - State:CA
Practice Address - Zip Code:95070-4158
Practice Address - Country:US
Practice Address - Phone:408-253-4806
Practice Address - Fax:408-257-9701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84144261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG29118Medicare UPIN