Healthcare Provider Details

I. General information

NPI: 1740258656
Provider Name (Legal Business Name): WILLIAM J WALTERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 07/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

923 E CENTRAL AVE
LA FOLLETTE TN
37766-2768
US

IV. Provider business mailing address

5220 BELFORT RD STE 130
JACKSONVILLE FL
32256-6017
US

V. Phone/Fax

Practice location:
  • Phone: 423-907-1200
  • Fax:
Mailing address:
  • Phone: 904-446-3451
  • Fax: 904-446-3013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number11726
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number11726
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: