Provider Demographics
NPI:1467436782
Name:SYDNOR, WALTON K III (MD)
Entity Type:Individual
Prefix:
First Name:WALTON
Middle Name:K
Last Name:SYDNOR
Suffix:III
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 11646
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24506-1646
Mailing Address - Country:US
Mailing Address - Phone:434-200-5895
Mailing Address - Fax:434-200-7529
Practice Address - Street 1:1901 TATE SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1109
Practice Address - Country:US
Practice Address - Phone:434-200-5895
Practice Address - Fax:434-200-7529
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101040738207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6061079Medicaid
VA110045837OtherMEDICARE RAILROAD CARRIER
P00789319OtherMEDICARE RAILROAD CARRIER
P00789319OtherMEDICARE RAILROAD CARRIER
VA110005990Medicare ID - Type Unspecified
VA022219C59Medicare PIN