Provider Demographics
NPI:1780173294
Name:WALTON, MOLLIE M (MD)
Entity type:Individual
Prefix:
First Name:MOLLIE
Middle Name:M
Last Name:WALTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CHILDRENS PLZ
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45404-1815
Mailing Address - Country:US
Mailing Address - Phone:937-641-3000
Mailing Address - Fax:
Practice Address - Street 1:3333 W TECH RD
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-0955
Practice Address - Country:US
Practice Address - Phone:937-641-5725
Practice Address - Fax:937-350-3050
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.140835208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0296930Medicaid