Provider Demographics
NPI:1487757977
Name:DAVIS, WALTER ETCHELLES (MD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:ETCHELLES
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:266 RIVER KNOLL PL
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:NC
Mailing Address - Zip Code:28640-9392
Mailing Address - Country:US
Mailing Address - Phone:336-982-3776
Mailing Address - Fax:
Practice Address - Street 1:184 VIRGINIA STREET
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607
Practice Address - Country:US
Practice Address - Phone:828-262-4332
Practice Address - Fax:828-265-5514
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15051174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0211XOtherBLUE CROSS BLUE SHIELD NC
NC890211XMedicaid
NC0211XOtherBLUE CROSS BLUE SHIELD NC
C80644Medicare UPIN