Provider Demographics
NPI:1316908809
Name:BOUTWELL, WALTER CLARK (MD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:CLARK
Last Name:BOUTWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:207 HUNTER TRL
Mailing Address - Street 2:
Mailing Address - City:PIKE ROAD
Mailing Address - State:AL
Mailing Address - Zip Code:36064-3415
Mailing Address - Country:US
Mailing Address - Phone:334-657-7198
Mailing Address - Fax:334-272-4876
Practice Address - Street 1:207 HUNTER TRL
Practice Address - Street 2:
Practice Address - City:PIKE ROAD
Practice Address - State:AL
Practice Address - Zip Code:36064-3415
Practice Address - Country:US
Practice Address - Phone:334-657-7198
Practice Address - Fax:334-272-4876
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-01
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-014439-E2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001312743Medicaid
MI4630520Medicaid
CT001312743Medicaid