Healthcare Provider Details

I. General information

NPI: 1528037116
Provider Name (Legal Business Name): WALTER M GORTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 08/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 CHURCH ST
BELZONI MS
39038-3929
US

IV. Provider business mailing address

PO BOX 633
BELZONI MS
39038-0633
US

V. Phone/Fax

Practice location:
  • Phone: 662-247-2105
  • Fax: 662-247-4849
Mailing address:
  • Phone: 662-247-2105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number05613
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: