Provider Demographics
NPI:1740490895
Name:WALTERS, JOSEPH A JR (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:A
Last Name:WALTERS
Suffix:JR
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:PO BOX 293
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71221-0293
Mailing Address - Country:US
Mailing Address - Phone:318-283-3620
Mailing Address - Fax:318-239-8620
Practice Address - Street 1:425 S VINE ST
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-4513
Practice Address - Country:US
Practice Address - Phone:318-283-3960
Practice Address - Fax:318-239-8960
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA203093207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1077038Medicaid
LA4M6415F600Medicare PIN