Provider Demographics
NPI:1841632247
Name:WALTERS, MARSHALL BANKER
Entity type:Individual
Prefix:MR
First Name:MARSHALL
Middle Name:BANKER
Last Name:WALTERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 EL DORADO AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5055
Mailing Address - Country:US
Mailing Address - Phone:530-828-9179
Mailing Address - Fax:
Practice Address - Street 1:1440 BROADWAY
Practice Address - Street 2:SUITE 610
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-2041
Practice Address - Country:US
Practice Address - Phone:510-628-9065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-25
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker