Provider Demographics
NPI:1396704904
Name:WALSWORTH, DAVID M (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:M
Last Name:WALSWORTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:201 MCMILLAN RD
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-5321
Mailing Address - Country:US
Mailing Address - Phone:318-387-6622
Mailing Address - Fax:318-387-6030
Practice Address - Street 1:201 MCMILLAN RD
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-5321
Practice Address - Country:US
Practice Address - Phone:318-387-6622
Practice Address - Fax:318-387-6030
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA013630207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1307360Medicaid
LA1356446801OtherLA DERMATOLOGY GROUP #
LA$$$$$$$$$AOtherBLUE CROSS
LA1307360Medicaid
LA$$$$$$$$$AOtherBLUE CROSS
LA1356446801OtherLA DERMATOLOGY GROUP #