Provider Demographics
NPI:1801996905
Name:WALKER, CHARLES G (DO)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:G
Last Name:WALKER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 VAUGHAN ST
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02347-1638
Mailing Address - Country:US
Mailing Address - Phone:774-213-5105
Mailing Address - Fax:774-213-5105
Practice Address - Street 1:15 VAUGHAN ST
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MA
Practice Address - Zip Code:02347-1638
Practice Address - Country:US
Practice Address - Phone:774-213-5105
Practice Address - Fax:774-213-5105
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA151536207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3160530Medicaid
MAA21867Medicare ID - Type UnspecifiedMEDICARE B
MA3160530Medicaid