Healthcare Provider Details

I. General information

NPI: 1346273760
Provider Name (Legal Business Name): WALTER HAROLD JOLLEY D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5222 BALBOA AVE SUITE 52
SAN DIEGO CA
92117-6904
US

IV. Provider business mailing address

5222 BALBOA AVE SUITE 52
SAN DIEGO CA
92117-6904
US

V. Phone/Fax

Practice location:
  • Phone: 858-560-0390
  • Fax: 858-560-0333
Mailing address:
  • Phone: 858-560-0390
  • Fax: 858-560-0333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE1540
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: