Provider Demographics
NPI:1548441389
Name:WALTER JOLLEY DPM A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:WALTER JOLLEY DPM A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:HAROLD
Authorized Official - Last Name:JOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:858-560-0390
Mailing Address - Street 1:5222 BALBOA AVE
Mailing Address - Street 2:SUITE 52
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-6904
Mailing Address - Country:US
Mailing Address - Phone:858-560-0390
Mailing Address - Fax:858-560-0333
Practice Address - Street 1:5222 BALBOA AVE
Practice Address - Street 2:SUITE 52
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-6904
Practice Address - Country:US
Practice Address - Phone:858-560-0390
Practice Address - Fax:858-560-0333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1540213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU16885Medicare UPIN