Provider Demographics
NPI:1831162825
Name:WALTERS, LAURA MARIE (MD)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:MARIE
Last Name:WALTERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911 E REZANOF DR
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-6602
Mailing Address - Country:US
Mailing Address - Phone:907-481-5000
Mailing Address - Fax:907-481-5030
Practice Address - Street 1:1911 E REZANOF DR
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6602
Practice Address - Country:US
Practice Address - Phone:907-481-5000
Practice Address - Fax:907-481-5030
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4067207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
920088665OtherCLINIC TAX ID
AKMD4067Medicaid
AK150459Medicare ID - Type Unspecified
AKMD4067Medicaid