Basic Information
| Provider Information | |||||||||
| NPI: | 1780650291 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAMAN | ||||||||
| FirstName: | WALTER | ||||||||
| MiddleName: | NICHOLAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6161 N STATE HIGHWAY 161 | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750382220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722587499 | ||||||||
| FaxNumber: | 9722570897 | ||||||||
| Practice Location | |||||||||
| Address1: | 6161 N STATE HIGHWAY 161 | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722587499 | ||||||||
| FaxNumber: | 9722570897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 08/24/2018 | ||||||||
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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 | 207Q00000X | G8701 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | G8701 | 01 | TX | LICENSE | OTHER |