Provider Demographics
NPI:1255321881
Name:WALTON, MICHAEL GLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GLEN
Last Name:WALTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 51008
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71135-1008
Mailing Address - Country:US
Mailing Address - Phone:318-798-9400
Mailing Address - Fax:318-798-3894
Practice Address - Street 1:1453 E BERT KOUN LOOP STE 112
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-6810
Practice Address - Country:US
Practice Address - Phone:318-798-9400
Practice Address - Fax:318-795-4656
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LAMD.021647207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR132755001Medicaid
LA060043277OtherRAILROAD MEDICARE
TX059411101Medicaid
LA1659525Medicaid
AR132755001Medicaid
LAG42113Medicare UPIN