Provider Demographics
NPI:1285794990
Name:WALTERS, MARK VINCENT (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:VINCENT
Last Name:WALTERS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 W MOUNT VERNON BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:MO
Mailing Address - Zip Code:65712-1940
Mailing Address - Country:US
Mailing Address - Phone:417-461-1155
Mailing Address - Fax:417-461-1155
Practice Address - Street 1:316 W MOUNT VERNON BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:MO
Practice Address - Zip Code:65712-1940
Practice Address - Country:US
Practice Address - Phone:417-461-1155
Practice Address - Fax:417-461-1155
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006467111N00000X, 171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO315015486OtherINDIVIDUAL PTAN
MO350039075OtherRAILROAD MEDICARE
MO990001294OtherMEDICARE GROUP LEGACY
MO350039075OtherRAILROAD MEDICARE
MO000031501Medicare PIN
MO315015486OtherINDIVIDUAL PTAN