Healthcare Provider Details

I. General information

NPI: 1124139738
Provider Name (Legal Business Name): ROLAND B WALTER MD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 12/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 EASTLAKE AVE E
SEATTLE WA
98109-1023
US

IV. Provider business mailing address

PO BOX 50095
SEATTLE WA
98145-5095
US

V. Phone/Fax

Practice location:
  • Phone: 206-288-6823
  • Fax: 206-288-6998
Mailing address:
  • Phone: 206-543-6420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License NumberMD00044240
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: