Provider Demographics
NPI:1306834957
Name:WALKER, BRIAN (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:WALKER
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 1:13847 E 14TH ST
Mailing Address - Street 2:SUITE 118
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-2632
Mailing Address - Country:US
Mailing Address - Phone:510-352-8400
Mailing Address - Fax:
Practice Address - Street 1:13847 E 14TH ST
Practice Address - Street 2:SUITE 118
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2632
Practice Address - Country:US
Practice Address - Phone:510-352-8400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43347208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4405629Medicaid
CA00G433470Medicare ID - Type Unspecified
CA4405629Medicaid