MEDICARE: WALTER M KIDWELL MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208VP0014X	Interventional Pain Medicine Physician	9263	NV

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	33452	OTHER	NV	MEDICARE ORIGINAL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	100791	OTHER	NV	GROUP

General Provider Information

NPI Number	:	1215977038
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WALTER M KIDWELL MD

Provider Business Mailing Address
First Line	:	4045 S BUFFALO DR
Second Line	:	A101-172
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-7479
Country	:	US
Telephone Number	:	702-878-8252
Fax Number	:	702-878-9096

Provider Business Practice Location Address
First Line	:	7435 W AZURE DR STE 190
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-4427
Country	:	US
Telephone Number	:	702-788-5252
Fax Number	:	702-878-9096

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	06/12/2019

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