MEDICARE: RICHARD C. WALTERS, M.D., P.C.

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	207N00000X	Dermatology Physician	R 5775	MO

General Provider Information

NPI Number	:	1720362973
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RICHARD C. WALTERS, M.D., P.C.

Provider Business Mailing Address
First Line	:	7511 BIG BEND BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63119-2103
Country	:	US
Telephone Number	:	314-961-7064
Fax Number	:	314-961-9991

Provider Business Practice Location Address
First Line	:	7511 BIG BEND BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63119-2103
Country	:	US
Telephone Number	:	314-961-7064
Fax Number	:	314-961-9991

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RICHARD C. WALTERS
Credential	:	M.D.
Telephone Number	:	314-961-7064

Provider Enumeration Date	:	10/06/2011
Last Update Date	:	10/06/2011

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