Provider Demographics
NPI:1528037116
Name:GORTON, WALTER M (MD)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:M
Last Name:GORTON
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 633
Mailing Address - Street 2:
Mailing Address - City:BELZONI
Mailing Address - State:MS
Mailing Address - Zip Code:39038-0633
Mailing Address - Country:US
Mailing Address - Phone:662-247-2105
Mailing Address - Fax:
Practice Address - Street 1:107 CHURCH ST
Practice Address - Street 2:
Practice Address - City:BELZONI
Practice Address - State:MS
Practice Address - Zip Code:39038-3929
Practice Address - Country:US
Practice Address - Phone:662-247-2105
Practice Address - Fax:662-247-4849
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05613207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS14079Medicaid
MS80261753Medicare PIN
MS80263001Medicare ID - Type Unspecified