Provider Demographics
NPI:1619079811
Name:WALTON, GARY MAURICE (DO)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:MAURICE
Last Name:WALTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 DERBY DR
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:AL
Mailing Address - Zip Code:36925-2117
Mailing Address - Country:US
Mailing Address - Phone:205-392-9656
Mailing Address - Fax:
Practice Address - Street 1:415 DERBY DR
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:AL
Practice Address - Zip Code:36925-2117
Practice Address - Country:US
Practice Address - Phone:205-392-9656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO-215207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000061066Medicaid
ALE49174Medicare UPIN
AL051503427Medicare PIN