Healthcare Provider Details

I. General information

NPI: 1699720516
Provider Name (Legal Business Name): WALTER DODARD DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 03/31/2020
Certification Date: 03/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 WASHINGTON ST
WATERTOWN NY
13601-4036
US

IV. Provider business mailing address

PO BOX 91
WATERTOWN NY
13601
US

V. Phone/Fax

Practice location:
  • Phone: 315-788-2003
  • Fax: 315-788-7087
Mailing address:
  • Phone: 315-782-4207
  • Fax: 315-782-8699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number226806
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: