Basic Information
| Provider Information | |||||||||
| NPI: | 1285966499 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAMUEL WALTERS D.O.,P.A. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 6531 103RD ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322107131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047722727 | ||||||||
| FaxNumber: | 9047721693 | ||||||||
| Practice Location | |||||||||
| Address1: | 6531 103RD ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322107131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047722727 | ||||||||
| FaxNumber: | 9047721693 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2010 | ||||||||
| LastUpdateDate: | 07/03/2010 | ||||||||
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| AuthorizedOfficialLastName: | WALTERS | ||||||||
| AuthorizedOfficialFirstName: | SAMUEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 9047722727 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | OS8337 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 261008600 | 05 | FL | MEDICAID |