Healthcare Provider Details

I. General information

NPI: 1205895448
Provider Name (Legal Business Name): DAVID WALT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 12/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 E SUNFLOWER RD SUITE 100A
CLEVELAND MS
38732-2800
US

IV. Provider business mailing address

810 E SUNFLOWER RD SUITE 100A
CLEVELAND MS
38732-2800
US

V. Phone/Fax

Practice location:
  • Phone: 662-843-3606
  • Fax: 662-846-1194
Mailing address:
  • Phone: 662-843-3606
  • Fax: 662-846-1194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number09199
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: