Provider Demographics
NPI:1306951751
Name:WARREN, WALTER G (DPM)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:G
Last Name:WARREN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7301 E 90TH ST
Mailing Address - Street 2:STE 112
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-1282
Mailing Address - Country:US
Mailing Address - Phone:317-773-7787
Mailing Address - Fax:317-773-2226
Practice Address - Street 1:1239 E 4TH ST RD
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-1839
Practice Address - Country:US
Practice Address - Phone:812-524-3338
Practice Address - Fax:812-524-3337
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000678213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000092305OtherBCBS
IN480024209OtherPALMETTO GBA RAILROAD
508770008OtherMEDICARE 2016
IN100140790AMedicaid
IN380042POtherSIHO
IN380042POtherSIHO
508770008OtherMEDICARE 2016
INT93588Medicare UPIN