Healthcare Provider Details

I. General information

NPI: 1801285044
Provider Name (Legal Business Name): DUANE WALTERS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2015
Last Update Date: 01/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 DIVISION ST
BALTIMORE MD
21217-3121
US

IV. Provider business mailing address

1501 DIVISION ST
BALTIMORE MD
21217-3121
US

V. Phone/Fax

Practice location:
  • Phone: 141-038-3830
  • Fax:
Mailing address:
  • Phone: 141-038-3830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberNU 10000119
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: