Basic Information
| Provider Information | |||||||||
| NPI: | 1952384844 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTON | ||||||||
| FirstName: | RALPH | ||||||||
| MiddleName: | GERALD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 95 EAST CHAUTAUQUA STREET | ||||||||
| Address2: | PO BOX 168 | ||||||||
| City: | MAYVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147570168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7167537107 | ||||||||
| FaxNumber: | 7167535367 | ||||||||
| Practice Location | |||||||||
| Address1: | 95 EAST CHAUTAUQUA STREET | ||||||||
| Address2: | |||||||||
| City: | MAYVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147570168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7167537107 | ||||||||
| FaxNumber: | 7167535367 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 02/29/2012 | ||||||||
| 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 | 2084P0800X | MD425467 | PA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 101395 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 00596016 | 05 | NY | MEDICAID | 131177-000 | 01 | MAGELLAN | OTHER | 105497 | 01 | HIGHMARK PAR W/ PREMIER | OTHER | 00105497 | 01 | HIGHMARK KHPW | OTHER | 028625 | 01 | VALUEOPTIONS | OTHER | 0007940410005 | 05 | PA | MEDICAID |