Provider Demographics
NPI:1699731489
Name:WALTER, RICHARD L (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:WALTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:18375 VENTURA BLVD
Mailing Address - Street 2:SUITE 614
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-4218
Mailing Address - Country:US
Mailing Address - Phone:818-908-8048
Mailing Address - Fax:818-908-8072
Practice Address - Street 1:5525 ETIWANDA AVE
Practice Address - Street 2:SUITE 318
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3647
Practice Address - Country:US
Practice Address - Phone:818-528-1270
Practice Address - Fax:818-528-1275
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2010-03-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG31570207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE02616Medicare UPIN
CAWG31570JMedicare PIN