Provider Demographics
NPI:1356529739
Name:DONALD R WALTERS MDPC
Entity type:Organization
Organization Name:DONALD R WALTERS MDPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:MDPC
Authorized Official - Phone:423-727-7711
Mailing Address - Street 1:212 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37683-1368
Mailing Address - Country:US
Mailing Address - Phone:423-727-7711
Mailing Address - Fax:423-727-0209
Practice Address - Street 1:212 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN CITY
Practice Address - State:TN
Practice Address - Zip Code:37683-1368
Practice Address - Country:US
Practice Address - Phone:423-727-7711
Practice Address - Fax:423-727-0209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD9597261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3383490Medicare PIN