Provider Demographics
NPI:1275628125
Name:MAYFIELD, WALTER G JR (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:G
Last Name:MAYFIELD
Suffix:JR
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 1:2403 WILLOW CHASE
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-8164
Mailing Address - Country:US
Mailing Address - Phone:662-680-4661
Mailing Address - Fax:
Practice Address - Street 1:830 S GLOSTER ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4934
Practice Address - Country:US
Practice Address - Phone:662-377-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19026207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
BM9382540OtherDEA #
I42423Medicare UPIN