Basic Information
| Provider Information | |||||||||
| NPI: | 1609816958 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTHER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4401 W MEMORIAL RD | ||||||||
| Address2: | SUITE 121 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731341785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057514664 | ||||||||
| FaxNumber: | 4057494651 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 NIELSON ST | ||||||||
| Address2: | EM DEPT | ||||||||
| City: | WATSONVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950762468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8317615613 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 03/24/2015 | ||||||||
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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 | 207P00000X | G40705 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1609816958 | 05 | CA | MEDICAID | G40705 | 01 | CA | ANTHEM BLUE CROSS | OTHER |