Basic Information
| Provider Information | |||||||||
| NPI: | 1770567976 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTON | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 321359 | ||||||||
| Address2: | |||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392321359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019361395 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1040 RIVER OAKS DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392329531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019335417 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2005 | ||||||||
| LastUpdateDate: | 06/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 06/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | 28855 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 165999705 | 05 | TX | MEDICAID | 165999701 | 05 | TX | MEDICAID | 165999702 | 05 | TX | MEDICAID | 165999704 | 05 | TX | MEDICAID |