Healthcare Provider Details

I. General information

NPI: 1104826429
Provider Name (Legal Business Name): WALTER W IMMEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5510 ALMA LN
SPRINGFIELD VA
22151-4012
US

IV. Provider business mailing address

5510 ALMA LN
SPRINGFIELD VA
22151-4012
US

V. Phone/Fax

Practice location:
  • Phone: 703-642-5990
  • Fax: 703-642-5003
Mailing address:
  • Phone: 703-642-5990
  • Fax: 703-642-5003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number0101039106
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: