Healthcare Provider Details

I. General information

NPI: 1821105859
Provider Name (Legal Business Name): MARY JANE WALTER D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 03/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 FLORIDA PARK DR
PALM COAST FL
32137
US

IV. Provider business mailing address

11 FLORIDA PARK DR
PALM COAST FL
32137
US

V. Phone/Fax

Practice location:
  • Phone: 386-445-4734
  • Fax: 386-445-8411
Mailing address:
  • Phone: 386-445-4734
  • Fax: 386-445-8411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO-1735
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberPO-1735
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License NumberPO1735
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License NumberPO1735
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO1735
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPO-1735
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: