Healthcare Provider Details

I. General information

NPI: 1215977038
Provider Name (Legal Business Name): WALTER M KIDWELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 06/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7435 W AZURE DR STE 190
LAS VEGAS NV
89130-4427
US

IV. Provider business mailing address

4045 S BUFFALO DR A101-172
LAS VEGAS NV
89147-7479
US

V. Phone/Fax

Practice location:
  • Phone: 702-788-5252
  • Fax: 702-878-9096
Mailing address:
  • Phone: 702-878-8252
  • Fax: 702-878-9096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number9263
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: