Provider Demographics
NPI:1912929472
Name:GAMMON, WALTER RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:RAY
Last Name:GAMMON
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 1:420 SPRING FOREST RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-7244
Mailing Address - Country:US
Mailing Address - Phone:252-752-4124
Mailing Address - Fax:252-758-8954
Practice Address - Street 1:420 SPRING FOREST RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7244
Practice Address - Country:US
Practice Address - Phone:252-752-4124
Practice Address - Fax:252-758-8954
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17355207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8934460Medicaid
NC34460OtherBCBC OF NC
NC70261OtherMEDCOST
NC206508AMedicare ID - Type Unspecified
NC8934460Medicaid