Healthcare Provider Details

I. General information

NPI: 1699772442
Provider Name (Legal Business Name): WILLIAM J WALTERS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 01/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1179 E PARIS AVE SE SUITE 220
GRAND RAPIDS MI
49546-3682
US

IV. Provider business mailing address

100 MICHIGAN ST NE MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-454-2004
  • Fax: 616-454-0061
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number5101011070
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: