MEDICARE: DR. JERRY H WALKER DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D-3839	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154310373
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY H WALKER DMD

Provider Business Mailing Address
First Line	:	390 SOUTH 3RD WEST
Second Line	:
City	:	SODA SPRINGS
State	:	ID
Zip	:	83276
Country	:	US
Telephone Number	:	208-547-2220
Fax Number	:	208-547-2224

Provider Business Practice Location Address
First Line	:	390 SOUTH 3RD WEST
Second Line	:
City	:	SODA SPRINGS
State	:	ID
Zip	:	83276
Country	:	US
Telephone Number	:	208-547-2220
Fax Number	:	208-547-2224

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2005
Last Update Date	:	05/26/2009

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