Healthcare Provider Details

I. General information

NPI: 1962768341
Provider Name (Legal Business Name): MICHAEL JOHN WALTERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 S GARNETT RD STE 300
TULSA OK
74146-5238
US

IV. Provider business mailing address

4500 S GARNETT RD STE 300
TULSA OK
74146-5238
US

V. Phone/Fax

Practice location:
  • Phone: 918-935-3550
  • Fax:
Mailing address:
  • Phone: 918-728-6194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number34629
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number34629
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD-21972
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: