Provider Demographics
NPI:1215469382
Name:WISWELL, WALTER THOMAS
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:THOMAS
Last Name:WISWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 VALENCIA DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-2533
Mailing Address - Country:US
Mailing Address - Phone:904-434-6281
Mailing Address - Fax:
Practice Address - Street 1:1818 VALENCIA DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-2533
Practice Address - Country:US
Practice Address - Phone:904-434-6281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program