Healthcare Provider Details

I. General information

NPI: 1184808065
Provider Name (Legal Business Name): WALTER J M PEDERSEN JR MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SUNNY ISLE PROF BLDG SUITE 3F
ST CROIX VI
00823-4423
US

IV. Provider business mailing address

PO BOX 7840
CHRISTIANSTED VI
00823-7840
US

V. Phone/Fax

Practice location:
  • Phone: 340-778-6110
  • Fax: 340-778-2919
Mailing address:
  • Phone: 340-778-6110
  • Fax: 340-778-2919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number653
License Number StateVI
# 2
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number653
License Number StateVI

VIII. Authorized Official

Name: WALTER J M PEDERSEN JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 340-778-6110