Provider Demographics
NPI:1215116017
Name:WALTON, MARC BRYAN
Entity type:Individual
Prefix:MR
First Name:MARC
Middle Name:BRYAN
Last Name:WALTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1485 INTERNATIONAL PKWY
Mailing Address - Street 2:
Mailing Address - City:HEATHROW
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5303
Mailing Address - Country:US
Mailing Address - Phone:800-798-6035
Mailing Address - Fax:888-798-6035
Practice Address - Street 1:2418 ERIE DR
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94519-2155
Practice Address - Country:US
Practice Address - Phone:215-888-4452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP003008L224Z00000X
CAOT2513224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAOP003008LOtherSTATE LICENSE
CAOTA2513OtherSTATE LICENSE