Provider Demographics
NPI:1194708545
Name:WALTERMIRE, JAMES A (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:A
Last Name:WALTERMIRE
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 1:1301 W 6TH AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4375
Mailing Address - Country:US
Mailing Address - Phone:405-743-0550
Mailing Address - Fax:405-743-1704
Practice Address - Street 1:1301 W 6TH AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4375
Practice Address - Country:US
Practice Address - Phone:405-743-0550
Practice Address - Fax:405-743-1704
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK92852085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKA002OtherCHAMPUS
OKA002OtherCHAMPUS