Provider Demographics
NPI:1962768341
Name:WALTERS, MICHAEL JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
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 1:4500 S GARNETT RD STE 300
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-5238
Mailing Address - Country:US
Mailing Address - Phone:918-728-6194
Mailing Address - Fax:
Practice Address - Street 1:4500 S GARNETT RD STE 300
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-5238
Practice Address - Country:US
Practice Address - Phone:918-935-3550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK346292085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty