Provider Demographics
NPI:1528081767
Name:WALTERS, DAVE
Entity type:Individual
Prefix:
First Name:DAVE
Middle Name:
Last Name:WALTERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13464 CULVER DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-5371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3144 JOHN R RD
Practice Address - Street 2:SUITE 200
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-5930
Practice Address - Country:US
Practice Address - Phone:248-743-0850
Practice Address - Fax:248-743-0851
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501006205225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E01877OtherBCBSM
MIP51430001Medicare PIN
MI0P51430Medicare PIN
MI0N64560Medicare PIN