Healthcare Provider Details

I. General information

NPI: 1174264907
Provider Name (Legal Business Name): KEITH NESTA WALTERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 JONESBORO RD STE 101A
FAIRBURN GA
30213-3544
US

IV. Provider business mailing address

1230 BAXTER ST
ATHENS GA
30606-3712
US

V. Phone/Fax

Practice location:
  • Phone: 770-400-4590
  • Fax:
Mailing address:
  • Phone: 706-389-3860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number13706
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: