Provider Demographics
NPI:1134101991
Name:WALTON, DAVID J (PT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:WALTON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4773 CLOUDCREST DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-9278
Mailing Address - Country:US
Mailing Address - Phone:541-857-4941
Mailing Address - Fax:541-734-7592
Practice Address - Street 1:2780 E BARNETT RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8343
Practice Address - Country:US
Practice Address - Phone:541-779-6146
Practice Address - Fax:541-734-7592
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3326225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR138029Medicaid
103303Medicare ID - Type Unspecified