Provider Demographics
NPI:1174501449
Name:CARNAHAN, WALTER EARL (DO)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:EARL
Last Name:CARNAHAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7900 AIRWAYS BLVD
Mailing Address - Street 2:BLDG A SUITE 6
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-4113
Mailing Address - Country:US
Mailing Address - Phone:662-536-4646
Mailing Address - Fax:662-536-4443
Practice Address - Street 1:7900 AIRWAYS BLVD
Practice Address - Street 2:BLDG A SUITE 6
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-4113
Practice Address - Country:US
Practice Address - Phone:662-536-4646
Practice Address - Fax:662-536-4443
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16014207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP01277326OtherRAILROAD MEDICARE
MS317363YR80Medicare PIN
F19030Medicare UPIN