Provider Demographics
NPI:1770524035
Name:WALTERS, KEVIN L (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:L
Last Name:WALTERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:415 JEFFERSON ST NORTH
Mailing Address - Street 2:TRI-COUNTY HOSPITAL
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-1296
Mailing Address - Country:US
Mailing Address - Phone:218-631-3510
Mailing Address - Fax:218-631-7587
Practice Address - Street 1:4 DEERWOOD AVE NW
Practice Address - Street 2:TRI-COUNTY HEALTH CARE WADENA CLINIC
Practice Address - City:WADENA
Practice Address - State:MN
Practice Address - Zip Code:56482-1296
Practice Address - Country:US
Practice Address - Phone:218-631-1360
Practice Address - Fax:218-631-7507
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN37842207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNMN100008OtherLHS/BANNERHEALTH #
MN768832OtherAMERICA'S PPO/ARAZ #
MN890222400Medicaid
MNDA9041015691OtherPREFERRED ONE #
MNHP19560OtherHEALTHPARTNERS #
MN0106027OtherMEDICA #
MN0106028OtherMEDICA #
MN13136OtherNDBS #
MN142299OtherUCARE #
MN0106020OtherMEDICA #
MN21526OtherSIOUX VALLEY #
MN080067408Medicare ID - Type UnspecifiedRR MEDICARE #
MN0106020OtherMEDICA #
MN0106028OtherMEDICA #
MN890222400Medicaid