Provider Demographics
NPI:1912296740
Name:WALTHER, STEPHEN S (DO)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:S
Last Name:WALTHER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:456 N. NEW BALLAS RD.
Mailing Address - Street 2:SUITE 304
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141
Mailing Address - Country:US
Mailing Address - Phone:314-567-6868
Mailing Address - Fax:314-567-0578
Practice Address - Street 1:456 N. NEW BALLAS RD.
Practice Address - Street 2:SUITE 304
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141
Practice Address - Country:US
Practice Address - Phone:314-567-6868
Practice Address - Fax:314-567-0578
Is Sole Proprietor?:No
Enumeration Date:2011-04-01
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A390200000X
MO2014010845208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program