Provider Demographics
NPI:1194890863
Name:BAIN, WALTER M (MD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:M
Last Name:BAIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:1303 MCCULLOUGH AVE
Mailing Address - Street 2:STE 242
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-5604
Mailing Address - Country:US
Mailing Address - Phone:210-226-8982
Mailing Address - Fax:210-227-1736
Practice Address - Street 1:1303 MCCULLOUGH AVE
Practice Address - Street 2:STE 242
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-5604
Practice Address - Country:US
Practice Address - Phone:210-226-8982
Practice Address - Fax:210-227-1736
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXE4184207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
742630478OtherCHAMPUS
TX082977201Medicaid
86M432OtherBCBS
TX082977201Medicaid
TXOOH98NMedicare ID - Type Unspecified