Provider Demographics
NPI:1215977038
Name:KIDWELL, WALTER M (MD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:M
Last Name:KIDWELL
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 1:4045 S BUFFALO DR
Mailing Address - Street 2:A101-172
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-7479
Mailing Address - Country:US
Mailing Address - Phone:702-878-8252
Mailing Address - Fax:702-878-9096
Practice Address - Street 1:7435 W AZURE DR STE 190
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-4427
Practice Address - Country:US
Practice Address - Phone:702-788-5252
Practice Address - Fax:702-878-9096
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9263208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV33452OtherMEDICARE ORIGINAL
NV100791OtherGROUP
NV050085272OtherME RR
NV100791OtherGROUP
NV100791OtherGROUP
NV33452OtherMEDICARE ORIGINAL