Provider Demographics
NPI:1700940590
Name:WALTERS, PATRICIA (DPM)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:WALTERS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18366 CLARK ST # 106
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3502
Mailing Address - Country:US
Mailing Address - Phone:818-345-5585
Mailing Address - Fax:
Practice Address - Street 1:18366 CLARK ST # 106
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3502
Practice Address - Country:US
Practice Address - Phone:818-345-5585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2502213E00000X, 213ES0000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0332940001Medicare NSC
CAT11363Medicare UPIN
CAE2502Medicare PIN