Provider Demographics
NPI:1417172925
Name:WALTON, LARSON DEAN (BA,AA,AA,AA,AA,AA,AA)
Entity Type:Individual
Prefix:MR
First Name:LARSON
Middle Name:DEAN
Last Name:WALTON
Suffix:
Gender:M
Credentials:BA,AA,AA,AA,AA,AA,AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 CRADDUCK RD
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-8442
Mailing Address - Country:US
Mailing Address - Phone:580-332-3699
Mailing Address - Fax:580-332-9828
Practice Address - Street 1:1308 CRADDUCK RD
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-8442
Practice Address - Country:US
Practice Address - Phone:580-332-3699
Practice Address - Fax:580-332-9828
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator