Provider Demographics
NPI:1902802457
Name:WALTER, GREGORY L (DC)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:L
Last Name:WALTER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8521 BARRENS RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-6705
Mailing Address - Country:US
Mailing Address - Phone:540-563-0487
Mailing Address - Fax:540-362-5025
Practice Address - Street 1:5219 PETERS CREEK RD NW
Practice Address - Street 2:SUITE 5
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-3864
Practice Address - Country:US
Practice Address - Phone:540-362-0811
Practice Address - Fax:540-362-5025
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2010-06-09
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
VA0104000425111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA018116OtherANTHEM PROVIDER NUMBER
VA018116OtherANTHEM PROVIDER NUMBER
VAT90929Medicare UPIN