Healthcare Provider Details

I. General information

NPI: 1104827120
Provider Name (Legal Business Name): WALTER KENNETH LOVE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 12/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 MAIN ST
WALDOBORO ME
04572-6037
US

IV. Provider business mailing address

PO BOX 309
WALDOBORO ME
04572
US

V. Phone/Fax

Practice location:
  • Phone: 207-832-5813
  • Fax: 207-832-3070
Mailing address:
  • Phone: 207-832-5813
  • Fax: 207-832-3070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number012987
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: