Provider Demographics
NPI:1730173360
Name:O'BRIEN, WALTER M (MD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:M
Last Name:O'BRIEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9815 SPRING RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-1453
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19415 DEERFIELD AVENUE, SUITE 112
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-8470
Practice Address - Country:US
Practice Address - Phone:703-724-1195
Practice Address - Fax:703-724-4495
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101038671208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1730173360Medicaid
VA7503300Medicaid
DC340018240OtherRR MEDICARE
VA7503326Medicaid
VA340017880OtherRRMEDICARE
D98518Medicare UPIN
DC000Z66L26Medicare PIN