Basic Information
| Provider Information | |||||||||
| NPI: | 1902819691 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTERS | ||||||||
| FirstName: | ALTON | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALTERS | ||||||||
| OtherFirstName: | ALTON 'AL' | ||||||||
| OtherMiddleName: | JOSEPH | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 98978 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891938978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022163346 | ||||||||
| FaxNumber: | 7026716883 | ||||||||
| Practice Location | |||||||||
| Address1: | 5230 BOULDER HWY STE 110 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891226077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029401560 | ||||||||
| FaxNumber: | 7029401561 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 02/15/2019 | ||||||||
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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 | 207R00000X | 4017 | NV | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4017 | 01 | NV | STATE LICENSE | OTHER | 1902819691 | 05 | NV | MEDICAID |