Provider Demographics
NPI:1376632703
Name:WALTON, JOHN EDMOND (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDMOND
Last Name:WALTON
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 1:402 MEMORIAL DRIVE EXTENSION
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29651
Mailing Address - Country:US
Mailing Address - Phone:864-877-0779
Mailing Address - Fax:864-877-7801
Practice Address - Street 1:402 MEMORIAL DRIVE EXTENSION
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29651
Practice Address - Country:US
Practice Address - Phone:864-877-0779
Practice Address - Fax:864-877-7801
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6530208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89133WFOtherMEDICAID
SC065306Medicaid
NC2017033Medicare UPIN
SC065306Medicaid