Provider Demographics
NPI:1912902537
Name:ELLISTON, WALTER (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:ELLISTON
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 1:3800 GAYLORD PKWY STE 830
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-9419
Mailing Address - Country:US
Mailing Address - Phone:469-800-5740
Mailing Address - Fax:469-800-7545
Practice Address - Street 1:3800 GAYLORD PKWY STE 830
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-9419
Practice Address - Country:US
Practice Address - Phone:469-800-5740
Practice Address - Fax:469-800-5746
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL96832084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH45059Medicare UPIN