Basic Information
| Provider Information | |||||||||
| NPI: | 1861489676 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KYLE | ||||||||
| FirstName: | WALTER | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 402319 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303842319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797097399 | ||||||||
| FaxNumber: | 4797097053 | ||||||||
| Practice Location | |||||||||
| Address1: | 5111 ROGERS AVE | ||||||||
| Address2: | STE 40M | ||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729032047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797097440 | ||||||||
| FaxNumber: | 4797097441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 08/23/2010 | ||||||||
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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 | C5072 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 105912001 | 05 | AR | MEDICAID | 100079640A | 05 | OK | MEDICAID |