Healthcare Provider Details

I. General information

NPI: 1376520742
Provider Name (Legal Business Name): GEORGE DEXTER WALCOTT JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 04/11/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4294 LOMAC ST
MONTGOMERY AL
36106-3604
US

IV. Provider business mailing address

PO BOX 370
FORTSON GA
31808-0370
US

V. Phone/Fax

Practice location:
  • Phone: 334-274-9000
  • Fax: 334-274-0857
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number23247
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number23247
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: