Healthcare Provider Details

I. General information

NPI: 1578856985
Provider Name (Legal Business Name): JERRY DON WALKUP JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2011
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2312 KNOB CREEK RD STE 208
JOHNSON CITY TN
37604-2367
US

IV. Provider business mailing address

2312 KNOB CREEK RD STE 208
JOHNSON CITY TN
37604-2367
US

V. Phone/Fax

Practice location:
  • Phone: 423-610-1099
  • Fax: 423-246-4300
Mailing address:
  • Phone: 423-610-1099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number0101256238
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: