Basic Information
| Provider Information | |||||||||
| NPI: | 1164405783 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALTERS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 107 E MOUNTAIN VIEW AVE | ||||||||
| Address2: | |||||||||
| City: | ELLENSBURG | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989265312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099626348 | ||||||||
| FaxNumber: | 5099628702 | ||||||||
| Practice Location | |||||||||
| Address1: | 1750 MCGILCHRIST ST SE STE 130 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973021691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9713042200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 07/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD199938 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.