Healthcare Provider Details

I. General information

NPI: 1285628891
Provider Name (Legal Business Name): JACQUELINE MACHE WALTERS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 01/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3630 SAVANNAH PL STE 100
DULUTH GA
30096-5028
US

IV. Provider business mailing address

5780 PEACHTREE DUNWOODY RD STE 300
ATLANTA GA
30342-1513
US

V. Phone/Fax

Practice location:
  • Phone: 678-474-0203
  • Fax: 678-474-0207
Mailing address:
  • Phone: 404-303-1224
  • Fax: 404-303-1325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number040275
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: