Provider Demographics
NPI:1609970896
Name:GAUNTT WALKER, SUSAN RAEDENE (MD)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:RAEDENE
Last Name:GAUNTT WALKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 E ANDERSON ST
Mailing Address - Street 2:A
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-5873
Mailing Address - Country:US
Mailing Address - Phone:817-596-7717
Mailing Address - Fax:817-596-7119
Practice Address - Street 1:712 E ANDERSON ST
Practice Address - Street 2:A
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5873
Practice Address - Country:US
Practice Address - Phone:817-596-7717
Practice Address - Fax:817-596-7119
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5445208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10029712OtherAMERIGROUP
TX120339002Medicaid