Healthcare Provider Details

I. General information

NPI: 1497716211
Provider Name (Legal Business Name): WALTER S FASOLAK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 02/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 APPLECROSS RD SOUTHERN PINES WOMENS HEALTH CENTER PC
SOUTHERN PINES NC
28387
US

IV. Provider business mailing address

PO BOX 749 SOUTHERN PINES WOMENS HEALTH CENTER PC
SOUTHERN PINES NC
28388-0749
US

V. Phone/Fax

Practice location:
  • Phone: 910-692-7928
  • Fax: 910-692-5962
Mailing address:
  • Phone: 910-692-7928
  • Fax: 910-692-5962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number39728
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: