Provider Demographics
NPI:1912955626
Name:GADBERRY, WALTER L (M D)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:L
Last Name:GADBERRY
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 BRYAN DR. SUITE 307
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701
Mailing Address - Country:US
Mailing Address - Phone:580-256-2820
Mailing Address - Fax:580-256-7336
Practice Address - Street 1:1400 BRYAN DR STE 307
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2158
Practice Address - Country:US
Practice Address - Phone:580-256-2820
Practice Address - Fax:580-256-7336
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19690208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100230600AMedicaid
OKF34684Medicare UPIN
OK100230600AMedicaid
OKOK700056Medicare PIN