Basic Information
Provider Information | |||||||||
NPI: | 1407876709 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALKER | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 66 WEST GILBERT ST | ||||||||
Address2: |   | ||||||||
City: | RED BANK | ||||||||
State: | NJ | ||||||||
PostalCode: | 07701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7322120051 | ||||||||
FaxNumber: | 7322120713 | ||||||||
Practice Location | |||||||||
Address1: | 125 PATERSON ST | ||||||||
Address2: | SUITE 5100B | ||||||||
City: | NEW BRUNSWICK | ||||||||
State: | NJ | ||||||||
PostalCode: | 089011962 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7322356512 | ||||||||
FaxNumber: | 7322356124 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/20/2006 | ||||||||
LastUpdateDate: | 09/20/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | MA39207 | NJ | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 0557706 | 05 | NJ |   | MEDICAID | 390002450 | 01 | NJ | R R MCR | OTHER |