Basic Information
| Provider Information | |||||||||
| NPI: | 1780303735 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALTERS | ||||||||
| FirstName: | DAVID | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5644 N MOODY AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606466126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202033872 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2211 N OAK PARK AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 607073351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7736225400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2022 | ||||||||
| LastUpdateDate: | 08/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 209025805 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.