Provider Demographics
NPI:1912092172
Name:WALSTATTER, BENNETT S (MD)
Entity Type:Individual
Prefix:
First Name:BENNETT
Middle Name:S
Last Name:WALSTATTER
Suffix:
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 1:1202 W OAK ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-2155
Mailing Address - Country:US
Mailing Address - Phone:616-754-2944
Mailing Address - Fax:616-754-2999
Practice Address - Street 1:1202 W OAK ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-2155
Practice Address - Country:US
Practice Address - Phone:616-754-2944
Practice Address - Fax:616-754-2999
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBW064603207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3443068Medicaid
MIA37083Medicare UPIN