Healthcare Provider Details

I. General information

NPI: 1922107911
Provider Name (Legal Business Name): WALTER C. BOARDWINE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 GORMAN AVE
ELKINS WV
26241-3147
US

IV. Provider business mailing address

812 GORMAN AVE
ELKINS WV
26241-3181
US

V. Phone/Fax

Practice location:
  • Phone: 304-636-3300
  • Fax:
Mailing address:
  • Phone: 304-637-9302
  • Fax: 304-637-9306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number38203
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number3019
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: