Healthcare Provider Details

I. General information

NPI: 1710378955
Provider Name (Legal Business Name): COURT CARROLL WALTERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2015
Last Update Date: 02/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 N SKINNER RD
ALLENSPARK CO
80510-0523
US

IV. Provider business mailing address

PO BOX 523
ALLENSPARK CO
80510-0523
US

V. Phone/Fax

Practice location:
  • Phone: 303-747-2461
  • Fax:
Mailing address:
  • Phone: 303-747-2461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0054782
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number29106
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9701191
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: