Provider Demographics
NPI:1376520742
Name:WALCOTT, GEORGE DEXTER JR (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:DEXTER
Last Name:WALCOTT
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:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-0370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4294 LOMAC ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-3604
Practice Address - Country:US
Practice Address - Phone:334-274-9000
Practice Address - Fax:334-274-0857
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL23247207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
51058987OtherBLUE CROSS
AL000094906Medicaid
13383OtherNCC/TYNET
7344060OtherAETNA
51509952OtherBLUE CROSS
AL000058987Medicaid
AL009998830Medicaid
200039740OtherRR MEDICARE
1819711OtherFIRST HEALTH
51094906OtherBLUE CROSS
910527OtherUNITED HEALTHCARE
I048Medicare PIN
051509952Medicare PIN
51094906OtherBLUE CROSS
H431Medicare PIN
H429Medicare PIN
7344060OtherAETNA
13383OtherNCC/TYNET
910527OtherUNITED HEALTHCARE
51509952OtherBLUE CROSS
000094906Medicare PIN