Provider Demographics
NPI:1912057183
Name:WALKIEWICZ, THOMAS WALTER (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:WALTER
Last Name:WALKIEWICZ
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 1:815 PENNSYLVANIA AVE
Mailing Address - Street 2:STE 510
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2224
Mailing Address - Country:US
Mailing Address - Phone:817-321-0937
Mailing Address - Fax:
Practice Address - Street 1:8440 WALNUT HILL LN
Practice Address - Street 2:STE 510
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-3833
Practice Address - Country:US
Practice Address - Phone:866-805-6711
Practice Address - Fax:214-345-5543
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN67612085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
145J0OtherBCBS