Healthcare Provider Details

I. General information

NPI: 1730195298
Provider Name (Legal Business Name): ERIC D WALKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 11/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2319 CORONADO ST
IDAHO FALLS ID
83404-7407
US

IV. Provider business mailing address

2319 CORONADO ST
IDAHO FALLS ID
83404-7407
US

V. Phone/Fax

Practice location:
  • Phone: 208-227-1200
  • Fax: 208-227-1212
Mailing address:
  • Phone: 208-227-1200
  • Fax: 208-227-1212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberM6984
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: