Provider Demographics
NPI:1457434912
Name:WALTERS, JEREMY A (MD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:A
Last Name:WALTERS
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 1:601 MEMORY LN
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-2231
Mailing Address - Country:US
Mailing Address - Phone:717-851-1405
Mailing Address - Fax:717-851-6969
Practice Address - Street 1:239 S BUTLER RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-8939
Practice Address - Country:US
Practice Address - Phone:717-273-8871
Practice Address - Fax:717-270-2452
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4242072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101002853Medicaid
PAMD424207OtherSTATE LICENSE
PA101002853Medicaid
PABW8189652OtherFEDERAL DEA