Provider Demographics
NPI:1255737243
Name:POPE, WALTER III
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:POPE
Suffix:III
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 1:575 PORT HARWICK
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-1232
Mailing Address - Country:US
Mailing Address - Phone:619-579-8373
Mailing Address - Fax:619-579-8155
Practice Address - Street 1:575 PORT HARWICK
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91913-1232
Practice Address - Country:US
Practice Address - Phone:619-579-8373
Practice Address - Fax:619-579-8155
Is Sole Proprietor?:No
Enumeration Date:2014-11-18
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 284096164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse