Healthcare Provider Details

I. General information

NPI: 1992225338
Provider Name (Legal Business Name): RYAN ALAN WALTERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2017
Last Update Date: 07/21/2022
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 POWELL DR
LEXINGTON SC
29072-9203
US

IV. Provider business mailing address

3209 COLONIAL DRIVE FAMILY MEDICAL CENTER
COLUMBIA SC
29203
US

V. Phone/Fax

Practice location:
  • Phone: 803-957-8400
  • Fax: 803-957-1939
Mailing address:
  • Phone: 803-434-6113
  • Fax: 803-434-8478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberLL40875
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number40875
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: