Healthcare Provider Details

I. General information

NPI: 1669524575
Provider Name (Legal Business Name): WALTHER R EVENHUIS M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 NORTHSIDE DR STE 200
MACON GA
31210-2574
US

IV. Provider business mailing address

3330 NORTHSIDE DR STE 200
MACON GA
31210-2574
US

V. Phone/Fax

Practice location:
  • Phone: 478-309-1809
  • Fax: 478-272-3589
Mailing address:
  • Phone: 478-309-1809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number111139
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: