1114185121 NPI number — RANDY D. WALKER, M.D., P.L.L.C.

Table of content: (NPI 1114185121)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114185121 NPI number — RANDY D. WALKER, M.D., P.L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RANDY D. WALKER, M.D., P.L.L.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1114185121
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 740
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DE QUEEN
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71832-0740
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-584-3000
Provider Business Mailing Address Fax Number:
870-584-3003

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1553 W COLLIN RAYE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DE QUEEN
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71832-3801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-584-3000
Provider Business Practice Location Address Fax Number:
870-584-3003
Provider Enumeration Date:
05/27/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WALKER
Authorized Official First Name:
RANDY
Authorized Official Middle Name:
DEAN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
870-584-3000

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 145639001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5L991 . This is a "ARKANSAS BLUE CROSS AND BLUE SHIELD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 145640002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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