Healthcare Provider Details

I. General information

NPI: 1255313789
Provider Name (Legal Business Name): GORDON LESLIE WALTERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 SAINT SEBASTIAN WAY SUITE 311
AUGUSTA GA
30901-2651
US

IV. Provider business mailing address

PO BOX 925
AUGUSTA GA
30903-0925
US

V. Phone/Fax

Practice location:
  • Phone: 706-724-3473
  • Fax: 706-724-3493
Mailing address:
  • Phone: 706-724-3473
  • Fax: 706-724-3493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number030919
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: