Provider Demographics
NPI:1932156692
Name:MEDLIN, WALTER SCOTT EDWARDS (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:SCOTT EDWARDS
Last Name:MEDLIN
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 1:1046 E 100 S
Mailing Address - Street 2:SUITE A
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1520
Mailing Address - Country:US
Mailing Address - Phone:406-694-2487
Mailing Address - Fax:801-746-2886
Practice Address - Street 1:1046 E 100 S
Practice Address - Street 2:SUITE A
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1520
Practice Address - Country:US
Practice Address - Phone:406-694-2487
Practice Address - Fax:801-746-2886
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47825-020208600000X
WAMD00037282208600000X
MT12854208600000X
UT8984752-1205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7762232OtherAETNA
WA0248634OtherL&I AND CRIME VICTIMS
WA1932156692Medicaid
MN976488700Medicaid
AKMD0608WMedicaid
WA1008MEOtherREGENCE
WA1008MEOtherREGENCE
WAG8881268Medicare PIN
WI012818100Medicare ID - Type Unspecified