Basic Information
| Provider Information | |||||||||
| NPI: | 1437122355 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALKER | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1000, DEPT 250 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012599200 | ||||||||
| FaxNumber: | 9013626618 | ||||||||
| Practice Location | |||||||||
| Address1: | 4250 FARONIA RD | ||||||||
| Address2: | STE 4 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381166527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013489600 | ||||||||
| FaxNumber: | 9017297051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 01/04/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 15172 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3005053 | 05 | TN | MEDICAID |