MEDICARE: DR. NATHAN FREDERICK WALTERS DMD

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	8066	KY
2	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	8066	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000000339061	OTHER	KY	BC/BS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265424907
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NATHAN FREDERICK WALTERS DMD

Provider Business Mailing Address
First Line	:	2800 CANNONS LN STE 200
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40205-2164
Country	:	US
Telephone Number	:	502-454-4885
Fax Number	:	502-452-1926

Provider Business Practice Location Address
First Line	:	2800 CANNONS LN STE 200
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40205-2164
Country	:	US
Telephone Number	:	502-454-4885
Fax Number	:	502-452-1926

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

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	11/12/2018

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