Basic Information
| Provider Information | |||||||||
| NPI: | 1972574267 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAIMON | ||||||||
| FirstName: | WALTER | ||||||||
| MiddleName: | NED | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 BRIAR HILL RD | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454193429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372999331 | ||||||||
| FaxNumber: | 9374962610 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 BRIAR HILL RD | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454193429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372999331 | ||||||||
| FaxNumber: | 9374962610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 09/23/2013 | ||||||||
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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 | 207Y00000X | 35045767 | OH | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | D45767 | 01 | HUMANA | OTHER | 1020053 | 01 | UNITEDHEALTHCARE | OTHER | 9125132 | 05 | OH | MEDICAID | 0640557 | 01 | AETNA | OTHER | 000000003862 | 01 | ANTHEM | OTHER |