Provider Demographics
NPI:1205804432
Name:OKALOOSA WALTON UROLOGY PA
Entity type:Organization
Organization Name:OKALOOSA WALTON UROLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-682-6333
Mailing Address - Street 1:1112 HOSPITAL RD
Mailing Address - Street 2:UNIT A
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6655
Mailing Address - Country:US
Mailing Address - Phone:850-682-6333
Mailing Address - Fax:
Practice Address - Street 1:1112 HOSPITAL RD
Practice Address - Street 2:UNIT A
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6655
Practice Address - Country:US
Practice Address - Phone:850-682-6333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21347AMedicare PIN