Basic Information
| Provider Information | |||||||||
| NPI: | 1235245028 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WALTER G WARREN DPM, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | COMPREHENSIVE FOOT & ANKLE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 707 | ||||||||
| Address2: | |||||||||
| City: | SEYMOUR | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472740707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8125243338 | ||||||||
| FaxNumber: | 8125243337 | ||||||||
| Practice Location | |||||||||
| Address1: | 1239 E 4TH STREET RD | ||||||||
| Address2: | |||||||||
| City: | SEYMOUR | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472741839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8125243338 | ||||||||
| FaxNumber: | 8125243337 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2006 | ||||||||
| LastUpdateDate: | 06/21/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WARREN | ||||||||
| AuthorizedOfficialFirstName: | WALTER | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8125243338 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DPM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 07000678 | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 380042P | 01 | IN | SIHO | OTHER | 0369030001 | 01 | IN | DMERC | OTHER | 000000092305 | 01 | IN | BCBS | OTHER | 480024209 | 01 | IN | PALMETTO GBA RAILROAD | OTHER | 100140790A | 05 | IN | MEDICAID |