Basic Information
Provider Information | |||||||||
NPI: | 1043281231 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GILBERT | ||||||||
FirstName: | WALTER | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | SR. | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 34800 BOB WILSON DR | ||||||||
Address2: | NMCSD, ATTN: MEDICAL STAFF SERVICES | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921341098 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6195326460 | ||||||||
FaxNumber: | 6195326299 | ||||||||
Practice Location | |||||||||
Address1: | 34800 BOB WILSON DR | ||||||||
Address2: | NMCSD, ATTN: MEDICAL STAFF SERVICES | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921341098 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6195326460 | ||||||||
FaxNumber: | 6195326299 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/27/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | G027526 | CA | X |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 2080A0000X | G027526 | CA | X |   | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
ID | Type | State | Issuer | Description | AG8143391 | 01 |   | DEA NUMBER | OTHER | G027526 | 01 | CA | MEDICAL LICENSE NUMBER | OTHER |