Provider Demographics
NPI:1174119580
Name:WALTER, THOMAS H
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:H
Last Name:WALTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6725 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-1953
Mailing Address - Country:US
Mailing Address - Phone:419-304-2486
Mailing Address - Fax:
Practice Address - Street 1:6725 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-1953
Practice Address - Country:US
Practice Address - Phone:419-304-2486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-19
Last Update Date:2020-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3110510Medicaid