Provider Demographics
NPI:1780728345
Name:WALTERS, JACK ALLISON JR (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:ALLISON
Last Name:WALTERS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:8335 WALNUT HILL LN
Mailing Address - Street 2:SUITE 215
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231
Mailing Address - Country:US
Mailing Address - Phone:214-696-8080
Mailing Address - Fax:214-696-2658
Practice Address - Street 1:8335 WALNUT HILL LN
Practice Address - Street 2:SUITE 215
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231
Practice Address - Country:US
Practice Address - Phone:214-696-8080
Practice Address - Fax:214-696-2658
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXE3797207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1235749D2OtherMEDICAID
TX1235749D4Medicaid
TX1235749D4Medicaid
TX1235749D2OtherMEDICAID