Provider Demographics
NPI:1740258656
Name:WALTERS, WILLIAM J (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:J
Last Name:WALTERS
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 1:5220 BELFORT RD STE 130
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6017
Mailing Address - Country:US
Mailing Address - Phone:904-446-3451
Mailing Address - Fax:904-446-3013
Practice Address - Street 1:923 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LA FOLLETTE
Practice Address - State:TN
Practice Address - Zip Code:37766-2768
Practice Address - Country:US
Practice Address - Phone:423-907-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11726208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3184458Medicaid
TNB04132Medicare UPIN
TN3184458Medicaid