Healthcare Provider Details

I. General information

NPI: 1497761092
Provider Name (Legal Business Name): BENITA J WALTON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 LYME RD STE 204A
HANOVER NH
03755-1221
US

IV. Provider business mailing address

45 LYME RD STE 204A
HANOVER NH
03755-1221
US

V. Phone/Fax

Practice location:
  • Phone: 603-277-9894
  • Fax: 603-277-9896
Mailing address:
  • Phone: 603-277-9894
  • Fax: 603-277-9896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number7858
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: