Provider Demographics
NPI:1699719179
Name:WALTON, KENNETH BRIAN (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:BRIAN
Last Name:WALTON
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 1:1058 BERMUDA RUN ROAD
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-0858
Mailing Address - Country:US
Mailing Address - Phone:912-871-7100
Mailing Address - Fax:912-871-7110
Practice Address - Street 1:1058 BERMUDA RUN ROAD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0858
Practice Address - Country:US
Practice Address - Phone:912-871-7100
Practice Address - Fax:912-871-7110
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA065436208G00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP01108293OtherRAILROAD MEDICARE
GA52343669OtherBCBS
GA626252OtherWELLCARE
GA003107922AMedicaid
GA014459259OtherAMERIGROUP
GA003107922AMedicaid
GA626252OtherWELLCARE