Healthcare Provider Details

I. General information

NPI: 1821525825
Provider Name (Legal Business Name): MITCHELL THOMAS WALTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2017
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11714 WILSON PARKE AVE STE 150
AUSTIN TX
78726-4061
US

IV. Provider business mailing address

6210 E HIGHWAY 290
AUSTIN TX
78723-1142
US

V. Phone/Fax

Practice location:
  • Phone: 737-247-7200
  • Fax: 512-406-7368
Mailing address:
  • Phone: 737-247-7200
  • Fax: 512-406-7368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberBP10059358
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: