Provider Demographics
NPI:1104802982
Name:ZAVALA, WALTER A (MD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:A
Last Name:ZAVALA
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 1:601 DELTONA BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-7174
Mailing Address - Country:US
Mailing Address - Phone:386-574-6079
Mailing Address - Fax:386-574-6934
Practice Address - Street 1:601 DELTONA BLVD
Practice Address - Street 2:STE 101
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-7174
Practice Address - Country:US
Practice Address - Phone:386-574-6079
Practice Address - Fax:386-574-6934
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68853207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
27721RMedicare ID - Type Unspecified
G14873Medicare UPIN