Provider Demographics
NPI:1710069828
Name:WALTERS, TROY O'NEIL (DPT)
Entity Type:Individual
Prefix:MR
First Name:TROY
Middle Name:O'NEIL
Last Name:WALTERS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:901-227-3255
Mailing Address - Fax:901-227-3205
Practice Address - Street 1:108 CLINTON PKWY
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4730
Practice Address - Country:US
Practice Address - Phone:601-926-2018
Practice Address - Fax:601-924-9746
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3649225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08855377Medicaid
MS08855377Medicaid
MS470221YJ5JMedicare PIN