Healthcare Provider Details

I. General information

NPI: 1841632247
Provider Name (Legal Business Name): MR. MARSHALL BANKER WALTERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2013
Last Update Date: 07/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 BROADWAY SUITE 610
OAKLAND CA
94612-2041
US

IV. Provider business mailing address

614 EL DORADO AVE APT 4
OAKLAND CA
94611-5055
US

V. Phone/Fax

Practice location:
  • Phone: 510-628-9065
  • Fax:
Mailing address:
  • Phone: 530-828-9179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: