Healthcare Provider Details

I. General information

NPI: 1558344127
Provider Name (Legal Business Name): MICHELLE WALTERS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 W SUNBRIDGE DR
FAYETTEVILLE AR
72703-1825
US

IV. Provider business mailing address

PO BOX 1523
FAYETTEVILLE AR
72702-1523
US

V. Phone/Fax

Practice location:
  • Phone: 479-442-6266
  • Fax: 479-521-3877
Mailing address:
  • Phone: 479-571-6038
  • Fax: 479-582-0222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberJ0332
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberE-14832
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: