Provider Demographics
NPI:1619005469
Name:WALTERS, KENNETH CHRISTIAN (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:CHRISTIAN
Last Name:WALTERS
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:PO BOX 936857
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6857
Mailing Address - Country:US
Mailing Address - Phone:910-667-7000
Mailing Address - Fax:910-662-8909
Practice Address - Street 1:2131 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7407
Practice Address - Country:US
Practice Address - Phone:910-667-7000
Practice Address - Fax:910-662-8909
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0696642086S0120X, 208600000X
NC2024-017212086S0120X, 208600000X
ARE-7272208600000X, 2086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery