Provider Demographics
NPI:1699788166
Name:WALTERS, CARRIE L (MD)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:L
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 1:345 E VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1202
Mailing Address - Country:US
Mailing Address - Phone:602-254-3151
Mailing Address - Fax:602-256-9581
Practice Address - Street 1:345 E VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1202
Practice Address - Country:US
Practice Address - Phone:602-254-3151
Practice Address - Fax:602-256-9581
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17443207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ272899Medicaid
NM00X1951Medicaid
AZ12197OtherHEALTHNET
AZAZ0254750OtherBLUE CROSS/BLUE SHIELD
AZ12197OtherHEALTHNET
AZWCJDR03Medicare ID - Type Unspecified