Healthcare Provider Details

I. General information

NPI: 1730132812
Provider Name (Legal Business Name): RICHARD C WALTERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 09/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3915 WATSON RD SUITE 201
SAINT LOUIS MO
63109-1251
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 314-878-5599
  • Fax: 314-833-5833
Mailing address:
  • Phone: 920-663-9016
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberR5775
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: