Healthcare Provider Details

I. General information

NPI: 1588753610
Provider Name (Legal Business Name): MARK WALTERS MO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 52ND STREET
OAKLAND CA
94609
US

IV. Provider business mailing address

5528 PACHECO BLVD A
PACHECO CA
94553
US

V. Phone/Fax

Practice location:
  • Phone: 510-428-3374
  • Fax: 510-601-3916
Mailing address:
  • Phone: 925-363-8170
  • Fax: 925-363-4995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberG85406
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: