Provider Demographics
NPI:1699772442
Name:WALTERS, WILLIAM J (DO)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:WALTERS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1179 E PARIS AVE SE
Practice Address - Street 2:SUITE 220
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3682
Practice Address - Country:US
Practice Address - Phone:616-454-2004
Practice Address - Fax:616-454-0061
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI51010110702084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM74000/003Medicare ID - Type Unspecified
0M74460 615Medicare PIN
MIG35821Medicare UPIN