Provider Demographics
NPI:1871489377
Name:WALTERS, MARK JOSEPH
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JOSEPH
Last Name:WALTERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:OH
Mailing Address - Zip Code:44254-1225
Mailing Address - Country:US
Mailing Address - Phone:330-691-0919
Mailing Address - Fax:
Practice Address - Street 1:650 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:OH
Practice Address - Zip Code:44254-1225
Practice Address - Country:US
Practice Address - Phone:330-691-0919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-13
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No172A00000XOther Service ProvidersDriver