Basic Information
| Provider Information | |||||||||
| NPI: | 1023056165 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | CAPWELL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5450 CLEARFORK MAIN ST STE 420 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761093559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177848268 | ||||||||
| FaxNumber: | 8173466173 | ||||||||
| Practice Location | |||||||||
| Address1: | 5450 CLEARFORK MAIN ST STE 420 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761093559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177848268 | ||||||||
| FaxNumber: | 8173466173 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 11/04/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | F3657 | TX | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 132237202 | 05 | TX | MEDICAID | 132237207 | 05 | TX | MEDICAID | 132237208 | 05 | TX | MEDICAID | 132237209 | 05 | TX | MEDICAID |