Provider Demographics
NPI:1073667390
Name:WALKER, MICHAEL STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:STEPHEN
Last Name:WALKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:415 FAIRVIEW AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-1923
Mailing Address - Country:US
Mailing Address - Phone:580-765-5569
Mailing Address - Fax:580-765-2020
Practice Address - Street 1:415 FAIRVIEW AVE STE 100
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-1923
Practice Address - Country:US
Practice Address - Phone:580-765-5569
Practice Address - Fax:580-765-2020
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK17720208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100142420AMedicaid