Provider Demographics
NPI:1922356633
Name:WALKER, CARL S III
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:S
Last Name:WALKER
Suffix:III
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 1:8 WILDER STREET
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1529
Mailing Address - Country:US
Mailing Address - Phone:508-944-6115
Mailing Address - Fax:508-584-0988
Practice Address - Street 1:8 WILDER ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1529
Practice Address - Country:US
Practice Address - Phone:508-944-6115
Practice Address - Fax:508-584-0988
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1609179258390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program