Provider Demographics
NPI:1902976707
Name:WALT, MICHAEL J (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:WALT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701-0159
Mailing Address - Country:US
Mailing Address - Phone:814-368-3123
Mailing Address - Fax:814-363-2701
Practice Address - Street 1:181 INTERSTATE PKWY
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-1041
Practice Address - Country:US
Practice Address - Phone:814-368-3123
Practice Address - Fax:814-363-2701
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS010755L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine