Provider Demographics
NPI:1821095142
Name:WALKER, DOUGLAS C (DO)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:C
Last Name:WALKER
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:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:TREMONTON
Mailing Address - State:UT
Mailing Address - Zip Code:84337-0278
Mailing Address - Country:US
Mailing Address - Phone:435-257-3684
Mailing Address - Fax:435-257-7554
Practice Address - Street 1:300 W 1440 S
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:UT
Practice Address - Zip Code:84312
Practice Address - Country:US
Practice Address - Phone:435-257-3684
Practice Address - Fax:435-257-7554
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT359239-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD2581Medicaid
G42424Medicare UPIN
UT000012267Medicare PIN
UT080172486Medicare PIN