1699717629 NPI number — JEANNINE T WALTERS DO

Table of content: JEANNINE T WALTERS DO (NPI 1699717629)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699717629 NPI number — JEANNINE T WALTERS DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALTERS
Provider First Name:
JEANNINE
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WALTERS
Provider Other First Name:
JEANNINE
Provider Other Middle Name:
T
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1699717629
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 173817
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80217-3817
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-306-7783
Provider Business Mailing Address Fax Number:
303-306-7753

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 BOISE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOVELAND
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80538-5006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-635-4071
Provider Business Practice Location Address Fax Number:
970-635-4177
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  O271 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: DR.0049739 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 83809261 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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