Provider Demographics
NPI:1457321325
Name:WALCOTT, DEXTER W (MD)
Entity Type:Individual
Prefix:
First Name:DEXTER
Middle Name:W
Last Name:WALCOTT
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 1:1513 LAKELAND DR.
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216
Mailing Address - Country:US
Mailing Address - Phone:601-354-4836
Mailing Address - Fax:601-354-2619
Practice Address - Street 1:1513 LAKELAND DR.
Practice Address - Street 2:SUITE 101
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-354-4836
Practice Address - Fax:601-354-2619
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10031207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00113910Medicaid
MS00112408Medicaid
030002483Medicare PIN
MS00112408Medicaid
57452Medicare UPIN
F57452Medicare UPIN