Provider Demographics
NPI:1427323401
Name:WOLTER, KEVIN DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DAVID
Last Name:WOLTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 OXFORD CT
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-1705
Mailing Address - Country:US
Mailing Address - Phone:860-536-2718
Mailing Address - Fax:
Practice Address - Street 1:43 OXFORD CT
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-1705
Practice Address - Country:US
Practice Address - Phone:860-536-2718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-09
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT027924208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice