Provider Demographics
NPI:1063564821
Name:ROETTINGER, WALTER FRANK II (MD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:FRANK
Last Name:ROETTINGER
Suffix:II
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 1:222 BELLEVUE AVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:RI
Mailing Address - Zip Code:02840-3515
Mailing Address - Country:US
Mailing Address - Phone:401-849-2826
Mailing Address - Fax:401-847-1695
Practice Address - Street 1:222 BELLEVUE AVE
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02840-3515
Practice Address - Country:US
Practice Address - Phone:401-849-2826
Practice Address - Fax:401-847-1695
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI4796208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9002051Medicaid
RI249002051Medicare PIN
RI9002051Medicaid