Provider Demographics
NPI:1982038360
Name:WALTON, DEMETRIUS
Entity Type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:
Last Name:WALTON
Suffix:
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 1:9050 PINES BLVD
Mailing Address - Street 2:415-408
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-6455
Mailing Address - Country:US
Mailing Address - Phone:305-454-9546
Mailing Address - Fax:305-705-3790
Practice Address - Street 1:9050 PINES BLVD
Practice Address - Street 2:415-408
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-6455
Practice Address - Country:US
Practice Address - Phone:305-454-9546
Practice Address - Fax:305-705-3790
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL171M00000XMedicaid