Healthcare Provider Details

I. General information

NPI: 1346340676
Provider Name (Legal Business Name): WALTER ALFRED DIVERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4109 JOHN ALDEN LN
LEXINGTON KY
40504-2043
US

IV. Provider business mailing address

4109 JOHN ALDEN LN
LEXINGTON KY
40504-2043
US

V. Phone/Fax

Practice location:
  • Phone: 859-281-4902
  • Fax:
Mailing address:
  • Phone: 859-281-4902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number0101054852
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: