Provider Demographics
NPI:1831135706
Name:BOYANTON, WALTER J III (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:J
Last Name:BOYANTON
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:ESTILL SPRINGS
Mailing Address - State:TN
Mailing Address - Zip Code:37330-0700
Mailing Address - Country:US
Mailing Address - Phone:931-649-5139
Mailing Address - Fax:931-649-2766
Practice Address - Street 1:300 SOUTH MAIN ST
Practice Address - Street 2:
Practice Address - City:ESTILL SPRINGS
Practice Address - State:TN
Practice Address - Zip Code:37330-0700
Practice Address - Country:US
Practice Address - Phone:931-649-5139
Practice Address - Fax:931-649-2766
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000017539207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNA79468Medicare UPIN