=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336367234
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOE WALTERS MD INC. A MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2007
-----------------------------------------------------
Last Update Date | 04/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12961 VILLAGE DRIVE SUITE 1
-----------------------------------------------------
City | SARATOGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95070-4158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-253-4806
-----------------------------------------------------
Fax | 408-257-9701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12961 VILLAGE DRIVE SUITE A
-----------------------------------------------------
City | SARATOGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95070-4158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-253-4806
-----------------------------------------------------
Fax | 408-257-9701
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOSEPH JOHN WALTERS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 408-253-4806
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | G84144
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------