Basic Information
| Provider Information | |||||||||
| NPI: | 1386931137 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALCOTT | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 635283 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452635283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593445555 | ||||||||
| FaxNumber: | 8593445552 | ||||||||
| Practice Location | |||||||||
| Address1: | 230 6TH ST | ||||||||
| Address2: | |||||||||
| City: | RISING SUN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 470401114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124382555 | ||||||||
| FaxNumber: | 8124383972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2011 | ||||||||
| LastUpdateDate: | 03/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01073293A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 201068210 | 05 | IN | MEDICAID |