Healthcare Provider Details

I. General information

NPI: 1053394643
Provider Name (Legal Business Name): WALTER D MERRITT III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 09/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8185 STATE HIGHWAY 789
LANDER WY
82520-2942
US

IV. Provider business mailing address

8185 STATE HIGHWAY 789
LANDER WY
82520-2942
US

V. Phone/Fax

Practice location:
  • Phone: 307-335-7555
  • Fax: 307-335-7999
Mailing address:
  • Phone: 307-335-7555
  • Fax: 307-335-7999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License NumberM5753
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: