MEDICARE: WALTER ELLISTON M.D.

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	2084P0800X	Psychiatry Physician	L9683	TX

General Provider Information

NPI Number	:	1912902537
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WALTER ELLISTON M.D.

Provider Business Mailing Address
First Line	:	3800 GAYLORD PKWY STE 830
Second Line	:
City	:	FRISCO
State	:	TX
Zip	:	75034-9419
Country	:	US
Telephone Number	:	469-800-5740
Fax Number	:	469-800-7545

Provider Business Practice Location Address
First Line	:	3800 GAYLORD PKWY STE 830
Second Line	:
City	:	FRISCO
State	:	TX
Zip	:	75034-9419
Country	:	US
Telephone Number	:	469-800-5740
Fax Number	:	469-800-5746

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

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	05/16/2023

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