Provider Demographics
NPI:1386691715
Name:WALTON, BETTY DERRELLENE (MD)
Entity type:Individual
Prefix:
First Name:BETTY
Middle Name:DERRELLENE
Last Name:WALTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 E MATILIJA ST
Mailing Address - Street 2:#110
Mailing Address - City:OJAI
Mailing Address - State:CA
Mailing Address - Zip Code:93023-2740
Mailing Address - Country:US
Mailing Address - Phone:805-208-5420
Mailing Address - Fax:
Practice Address - Street 1:3800 JANES RD
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-4742
Practice Address - Country:US
Practice Address - Phone:925-225-5837
Practice Address - Fax:925-225-5838
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG23506207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G235060Medicaid
A41972Medicare UPIN