Provider Demographics
NPI:1285966499
Name:SAMUEL WALTERS D.O.,P.A.
Entity type:Organization
Organization Name:SAMUEL WALTERS D.O.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:904-772-2727
Mailing Address - Street 1:6531 103RD ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-7131
Mailing Address - Country:US
Mailing Address - Phone:904-772-2727
Mailing Address - Fax:904-772-1693
Practice Address - Street 1:6531 103RD ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-7131
Practice Address - Country:US
Practice Address - Phone:904-772-2727
Practice Address - Fax:904-772-1693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-12
Last Update Date:2010-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8337261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261008600Medicaid
FLCV529AMedicare PIN
FLH04251Medicare UPIN