Healthcare Provider Details

I. General information

NPI: 1477243228
Provider Name (Legal Business Name): MITCHELL C JOSEPH WALTERS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11380 ILLINOIS ST
CARMEL IN
46032-9840
US

IV. Provider business mailing address

679 E COUNTY LINE RD
GREENWOOD IN
46143-1049
US

V. Phone/Fax

Practice location:
  • Phone: 877-362-2778
  • Fax:
Mailing address:
  • Phone: 317-859-7222
  • Fax: 317-859-4269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10004038A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: