Provider Demographics
NPI:1699791673
Name:WALTERS, THOMAS JULIAN WRIGHT (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JULIAN WRIGHT
Last Name:WALTERS
Suffix:
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 1:4302 GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:NY
Mailing Address - Zip Code:14454-9449
Mailing Address - Country:US
Mailing Address - Phone:585-295-5450
Mailing Address - Fax:585-447-9804
Practice Address - Street 1:4302 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:NY
Practice Address - Zip Code:14454-9449
Practice Address - Country:US
Practice Address - Phone:585-295-5450
Practice Address - Fax:585-447-9804
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY240657207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02784985Medicaid
NYI61137Medicare UPIN
NY02784985Medicaid
NYRB1031Medicare PIN