Provider Demographics
NPI:1760611529
Name:WALKER, DERRICK W (MD)
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:W
Last Name:WALKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:317-355-7199
Mailing Address - Fax:317-355-9022
Practice Address - Street 1:7910 E WASHINGTON ST
Practice Address - Street 2:SUITE 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-2890
Practice Address - Country:US
Practice Address - Phone:317-355-7171
Practice Address - Fax:317-355-9022
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01068282A207Q00000X
IN11015165A390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201060400Medicaid
INP01157069OtherRR MEDICARE PTAN
INP01157069OtherRR MEDICARE PTAN