Basic Information
| Provider Information | |||||||||
| NPI: | 1760611529 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALKER | ||||||||
| FirstName: | DERRICK | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173557199 | ||||||||
| FaxNumber: | 3173559022 | ||||||||
| Practice Location | |||||||||
| Address1: | 7910 E WASHINGTON ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462192890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173557171 | ||||||||
| FaxNumber: | 3173559022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2009 | ||||||||
| LastUpdateDate: | 02/06/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01068282A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | 11015165A | IN | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 201060400 | 05 | IN | MEDICAID | P01157069 | 01 | IN | RR MEDICARE PTAN | OTHER |