Provider Demographics
NPI:1063573343
Name:WALCOTT, KATHYANN M (MD)
Entity type:Individual
Prefix:DR
First Name:KATHYANN
Middle Name:M
Last Name:WALCOTT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:12201 PLUM ORCHARD DRIVE
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-7803
Practice Address - Country:US
Practice Address - Phone:301-572-1000
Practice Address - Fax:301-572-3302
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD039141207Q00000X
VA0101248385207Q00000X
MDD54099207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
016067K92Medicare ID - Type Unspecified
G97043Medicare UPIN