Provider Demographics
NPI:1780792374
Name:GRIFFITH, WALTER G JR (MD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:G
Last Name:GRIFFITH
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 55156
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33732-5156
Mailing Address - Country:US
Mailing Address - Phone:727-577-1203
Mailing Address - Fax:727-577-0983
Practice Address - Street 1:5565 DR MARTIN LUTHER KING JR ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33703-1203
Practice Address - Country:US
Practice Address - Phone:727-577-1203
Practice Address - Fax:727-577-0983
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME619132084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17725Medicare ID - Type Unspecified
E41745Medicare UPIN