MEDICARE: DR. SUSAN ANNE WALSTRA M.D.

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	01034161A	IN

General Provider Information

NPI Number	:	1790076453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN ANNE WALSTRA M.D.

Provider Business Mailing Address
First Line	:	4601 HEATHERWIND DR
Second Line	:	APT. D
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-7135
Country	:	US
Telephone Number	:	260-420-1433
Fax Number	:	260-745-3643

Provider Business Practice Location Address
First Line	:	4601 HEATHERWIND DR
Second Line	:	APT. D
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-7135
Country	:	US
Telephone Number	:	260-420-1433
Fax Number	:	260-745-3643

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

Provider Enumeration Date	:	04/28/2011
Last Update Date	:	04/28/2011

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