Provider Demographics
NPI:1588753610
Name:WALTERS, MARK (MO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WALTERS
Suffix:
Gender:M
Credentials:MO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5528 PACHECO BLVD A
Mailing Address - Street 2:
Mailing Address - City:PACHECO
Mailing Address - State:CA
Mailing Address - Zip Code:94553
Mailing Address - Country:US
Mailing Address - Phone:925-363-8170
Mailing Address - Fax:925-363-4995
Practice Address - Street 1:747 52ND STREET
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609
Practice Address - Country:US
Practice Address - Phone:510-428-3374
Practice Address - Fax:510-601-3916
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG854062080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G854060Medicaid
00G854060Medicare ID - Type Unspecified
F16354Medicare UPIN