Provider Demographics
NPI:1205895448
Name:WALT, DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:WALT
Suffix:
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 1:810 E SUNFLOWER RD
Mailing Address - Street 2:SUITE 100A
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-2800
Mailing Address - Country:US
Mailing Address - Phone:662-843-3606
Mailing Address - Fax:662-846-1194
Practice Address - Street 1:810 E SUNFLOWER RD
Practice Address - Street 2:SUITE 100A
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2800
Practice Address - Country:US
Practice Address - Phone:662-843-3606
Practice Address - Fax:662-846-1194
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09199207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115142Medicaid
MSP00232468OtherMEDICARE RAILROAD
MS00115142Medicaid
MS00115142Medicaid