Provider Demographics
NPI:1265491062
Name:WALTERHOUSE, DAVID OTTO (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:OTTO
Last Name:WALTERHOUSE
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2300 CHILDRENS PLAZA
Mailing Address - Street 2:DIVISION OF HEMATOLOGY/ONCOLOGY BOX 30
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614
Mailing Address - Country:US
Mailing Address - Phone:773-755-6514
Mailing Address - Fax:773-880-3223
Practice Address - Street 1:2300 CHILDRENS PLAZA
Practice Address - Street 2:DIVISION OF HEMATOLOGY/ONCOLOGY BOX 30
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614
Practice Address - Country:US
Practice Address - Phone:773-755-6514
Practice Address - Fax:773-880-3223
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL0360790822080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036079082Medicaid
ILL03820Medicare ID - Type Unspecified
E18622Medicare UPIN