Provider Demographics
NPI:1427132695
Name:WALLINGFORD, WALTER RUDOLPH (MD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:RUDOLPH
Last Name:WALLINGFORD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 EXECUTIVE DR
Mailing Address - Street 2:SUITE 6C
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-2499
Mailing Address - Country:US
Mailing Address - Phone:757-874-7246
Mailing Address - Fax:757-826-9415
Practice Address - Street 1:2115 EXECUTIVE DR
Practice Address - Street 2:SUITE 6C
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2499
Practice Address - Country:US
Practice Address - Phone:757-874-7246
Practice Address - Fax:757-826-9415
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101024223207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA15635OtherOPTIMA
541005350OtherCOMMERCIAL INSURANCE
VA15635Other15635
VA002129OtherANTHEM BLUE CROSS & BLUE
VA006045847Medicaid
VA15635OtherOPTIMA
B08838Medicare UPIN