MEDICARE: MITCHELL THOMAS WALTERS

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	174400000X	Specialist		CA

General Provider Information

NPI Number	:	1619853470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MITCHELL THOMAS WALTERS

Provider Business Mailing Address
First Line	:	8652 SUNSET AVE
Second Line	:
City	:	FAIR OAKS
State	:	CA
Zip	:	95628-5305
Country	:	US
Telephone Number	:	916-941-0491
Fax Number	:

Provider Business Practice Location Address
First Line	:	4610 X ST
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95817-2200
Country	:	US
Telephone Number	:	530-941-0491
Fax Number	:

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

Provider Enumeration Date	:	08/15/2025
Last Update Date	:	01/29/2026

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