=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245230655
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAY R WALTHER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2005
-----------------------------------------------------
Last Update Date | 08/04/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 628 N ED CAREY DR
-----------------------------------------------------
City | HARLINGEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78550-7912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-423-1121
-----------------------------------------------------
Fax | 956-423-1202
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 628 N ED CAREY DR
-----------------------------------------------------
City | HARLINGEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78550-7912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-423-1121
-----------------------------------------------------
Fax | 956-423-1202
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | G2301
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------