Provider Demographics
NPI:1609884394
Name:TOLBERT-WALKER, DERRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:
Last Name:TOLBERT-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 1:603 W 148TH ST
Mailing Address - Street 2:7B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-3130
Mailing Address - Country:US
Mailing Address - Phone:917-239-0168
Mailing Address - Fax:212-245-0915
Practice Address - Street 1:603 W 148TH ST
Practice Address - Street 2:7B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-3130
Practice Address - Country:US
Practice Address - Phone:917-239-0168
Practice Address - Fax:212-245-0915
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203716207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01714332Medicaid
NY01714332Medicaid
NY01714332Medicaid