Provider Demographics
NPI:1760433601
Name:WALKER, ELOISA S (MD)
Entity Type:Individual
Prefix:DR
First Name:ELOISA
Middle Name:S
Last Name:WALKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712
Mailing Address - Country:US
Mailing Address - Phone:208-337-4254
Mailing Address - Fax:208-337-4328
Practice Address - Street 1:100 E IDAHO ST
Practice Address - Street 2:SUITE 304
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6223
Practice Address - Country:US
Practice Address - Phone:208-336-9188
Practice Address - Fax:208-336-2636
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM62792080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0027267Medicaid
OR121173OtherOMAP (OREGON MEDICAID)
ID12799OtherBLUE CROSS
ID00010017912OtherBLUE SHIELD
ID1129459Medicare PIN
ID0027267Medicaid