Basic Information
| Provider Information | |||||||||
| NPI: | 1902976707 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALT | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 159 | ||||||||
| Address2: | |||||||||
| City: | BRADFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 167010159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143683123 | ||||||||
| FaxNumber: | 8143632701 | ||||||||
| Practice Location | |||||||||
| Address1: | 181 INTERSTATE PKWY | ||||||||
| Address2: | |||||||||
| City: | BRADFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 167011041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143683123 | ||||||||
| FaxNumber: | 8143632701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS010755L | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.