Provider Demographics
NPI:1063598431
Name:WALTER, ERICH WERNER (DC)
Entity type:Individual
Prefix:
First Name:ERICH
Middle Name:WERNER
Last Name:WALTER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15700 MICHIGAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2903
Mailing Address - Country:US
Mailing Address - Phone:313-582-4334
Mailing Address - Fax:
Practice Address - Street 1:15700 MICHIGAN AVENUE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2903
Practice Address - Country:US
Practice Address - Phone:313-582-4334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-28
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004603111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1837386Medicaid
MI95OH25106OtherBCBSM
MI11291535OtherCAQH
T33692Medicare UPIN
MI1837386Medicaid