Provider Demographics
NPI:1730125568
Name:WALTON, PHILLIP GENE
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:GENE
Last Name:WALTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3995 COVINGTON HWY
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-2645
Mailing Address - Country:US
Mailing Address - Phone:404-284-6911
Mailing Address - Fax:404-288-4165
Practice Address - Street 1:3995 COVINGTON HWY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-2645
Practice Address - Country:US
Practice Address - Phone:404-284-6911
Practice Address - Fax:404-288-4165
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0089711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA9180345OtherAMERIGROUP MEDICADE
GA00213056AMedicaid
GA9180345OtherAMERIGROUP MEDICADE