Provider Demographics
NPI:1861414179
Name:TOM, WALTER W (MD, FACS)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:W
Last Name:TOM
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 FARMERS LN STE 6B
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4768
Mailing Address - Country:US
Mailing Address - Phone:707-542-8346
Mailing Address - Fax:707-542-9173
Practice Address - Street 1:170 FARMERS LN STE 6B
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4768
Practice Address - Country:US
Practice Address - Phone:707-542-8346
Practice Address - Fax:707-542-9173
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57374174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA53274Medicare UPIN
CA00G573740Medicare ID - Type Unspecified