Provider Demographics
NPI:1427057108
Name:WARREN, WALTER RICHARD (MD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:RICHARD
Last Name:WARREN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2697
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-2697
Mailing Address - Country:US
Mailing Address - Phone:270-745-1467
Mailing Address - Fax:270-745-1156
Practice Address - Street 1:825 SECOND AVENUE EAST
Practice Address - Street 2:SUITE A3
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101
Practice Address - Country:US
Practice Address - Phone:270-796-6847
Practice Address - Fax:270-796-6841
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY187102084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64187107Medicaid
C69319Medicare UPIN
0701101Medicare ID - Type Unspecified