Healthcare Provider Details

I. General information

NPI: 1255495446
Provider Name (Legal Business Name): DAN G. WALTERS, M.D. A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 01/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77564 COUNTRY CLUB DR SUITE 408
PALM DESERT CA
92211-0484
US

IV. Provider business mailing address

77564 COUNTRY CLUB DR SUITE 408
PALM DESERT CA
92211-0484
US

V. Phone/Fax

Practice location:
  • Phone: 760-898-2968
  • Fax: 760-345-3888
Mailing address:
  • Phone: 760-898-2968
  • Fax: 760-345-3888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberG39049
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberG39049
License Number StateCA

VIII. Authorized Official

Name: DR. DAN G WALTERS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 760-327-8405