Provider Demographics
NPI:1477649911
Name:WALTERS, MARIANNE MARGARET (MD)
Entity type:Individual
Prefix:DR
First Name:MARIANNE
Middle Name:MARGARET
Last Name:WALTERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5358 MARETTA DR
Mailing Address - Street 2:
Mailing Address - City:SOQUEL
Mailing Address - State:CA
Mailing Address - Zip Code:95073-2756
Mailing Address - Country:US
Mailing Address - Phone:831-475-8797
Mailing Address - Fax:
Practice Address - Street 1:5358 MARETTA DR
Practice Address - Street 2:
Practice Address - City:SOQUEL
Practice Address - State:CA
Practice Address - Zip Code:95073-2756
Practice Address - Country:US
Practice Address - Phone:831-475-8797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48552207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA51097Medicare UPIN