1013208495 NPI number — DERREL V WALKER M.D.

Table of content: DERREL V WALKER M.D. (NPI 1013208495)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013208495 NPI number — DERREL V WALKER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALKER
Provider First Name:
DERREL
Provider Middle Name:
V
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013208495
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3340 E GOLDSTONE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642-1026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-367-7350
Provider Business Mailing Address Fax Number:
208-367-3951

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1055 N CURTIS ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-367-7350
Provider Business Practice Location Address Fax Number:
208-367-3951
Provider Enumeration Date:
04/20/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  M-12121 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)