Provider Demographics
NPI:1104837178
Name:WALKO, MARTIN S (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:S
Last Name:WALKO
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 1:425 BLACK WALNUT DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN TOP
Mailing Address - State:PA
Mailing Address - Zip Code:18707-1566
Mailing Address - Country:US
Mailing Address - Phone:443-481-6538
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:6 TSIENNETO RD
Practice Address - Street 2:
Practice Address - City:DERRY
Practice Address - State:NH
Practice Address - Zip Code:03038-1584
Practice Address - Country:US
Practice Address - Phone:603-434-7444
Practice Address - Fax:603-434-1733
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD061845L208600000X
NH10637208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0RE5299Medicaid
MD911003800Medicaid
PA1031721820001Medicaid
NH3081247Medicaid
VTHX4003Medicare PIN
VT0RE5299Medicaid