Provider Demographics
NPI:1528087962
Name:WEST, WALTER CLINTON II (MD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:CLINTON
Last Name:WEST
Suffix:II
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 1:445 E CHEYENNE MOUNTAIN BLVD STE C PMB 406
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-4570
Mailing Address - Country:US
Mailing Address - Phone:719-538-8100
Mailing Address - Fax:719-538-8003
Practice Address - Street 1:1008 MINNEQUA AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3733
Practice Address - Country:US
Practice Address - Phone:719-560-5656
Practice Address - Fax:719-560-4715
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO26226174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01262260Medicaid
CO2370237OtherAETNA
CO84145895001OtherPACIFICARE
CO84145895001OtherPACIFICARE
CO84145895001OtherPACIFICARE
COC383638Medicare PIN