Provider Demographics
NPI:1386078418
Name:WALTERS, SHELLY D (MD)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:D
Last Name:WALTERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:D
Other - Last Name:THEOBALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:301 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:OROFINO
Mailing Address - State:ID
Mailing Address - Zip Code:83544-9029
Mailing Address - Country:US
Mailing Address - Phone:208-476-4555
Mailing Address - Fax:208-476-5385
Practice Address - Street 1:1921 STONECIPHER DR
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-3439
Practice Address - Country:US
Practice Address - Phone:580-436-3980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-26
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML60390210207Q00000X
IDM-15041207Q00000X
OK38491207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine