Healthcare Provider Details

I. General information

NPI: 1154363315
Provider Name (Legal Business Name): WALTER CHATHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 06/30/2023
Certification Date: 06/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 W CHARLESTON BLVD STE 230
LAS VEGAS NV
89102-2353
US

IV. Provider business mailing address

3016 W CHARLESTON BLVD STE 100
LAS VEGAS NV
89102-1973
US

V. Phone/Fax

Practice location:
  • Phone: 702-671-6469
  • Fax:
Mailing address:
  • Phone: 702-780-2315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number12575
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: