Basic Information
| Provider Information | |||||||||
| NPI: | 1598779662 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | NICHOLAS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 590 COURT STREET | ||||||||
| Address2: | FAMILY MED | ||||||||
| City: | KEENE | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6033545400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 590 COURT STREET | ||||||||
| Address2: | FAMILY MED | ||||||||
| City: | KEENE | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6033545400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 07/31/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 8246 | NH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0RE0614 | 05 | VT | MEDICAID | 3074768 | 05 | NH | MEDICAID |