Provider Demographics
NPI:1437122355
Name:WALKER, LARRY M (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:M
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:PO BOX 1000, DEPT 250
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0250
Mailing Address - Country:US
Mailing Address - Phone:901-259-9200
Mailing Address - Fax:901-362-6618
Practice Address - Street 1:4250 FARONIA RD
Practice Address - Street 2:STE 4
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-6527
Practice Address - Country:US
Practice Address - Phone:901-348-9600
Practice Address - Fax:901-729-7051
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15172207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3005053Medicaid
TNA96987Medicare UPIN
TN3005050Medicare ID - Type Unspecified