Healthcare Provider Details

I. General information

NPI: 1013950955
Provider Name (Legal Business Name): SUSAN DIANA WALKER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 05/13/2022
Certification Date: 05/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 MAIN ST STE A
CENTER MORICHES NY
11934-2235
US

IV. Provider business mailing address

PO BOX 1559
STONY BROOK NY
11790-0989
US

V. Phone/Fax

Practice location:
  • Phone: 631-638-2900
  • Fax:
Mailing address:
  • Phone: 631-444-0650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number211855
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: