Healthcare Provider Details

I. General information

NPI: 1194851063
Provider Name (Legal Business Name): WALTER EUGENE EGERTON III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 E HERNDON AVE
FRESNO CA
93720
US

IV. Provider business mailing address

175 CAMPUS LAKES CT
BEL AIR MD
21015-1713
US

V. Phone/Fax

Practice location:
  • Phone: 559-450-7098
  • Fax: 559-450-4238
Mailing address:
  • Phone: 410-734-0211
  • Fax: 410-734-6610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25492
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD034443
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number180846
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberD0059017
License Number StateMD
# 5
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberC146978
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: