Provider Demographics
NPI:1972549087
Name:WALTON, CHARLENE (MD)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:WALTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHARLENE
Other - Middle Name:
Other - Last Name:WALTON-RILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 6069
Mailing Address - Street 2:DEPT 110
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-6069
Mailing Address - Country:US
Mailing Address - Phone:317-567-2179
Mailing Address - Fax:317-567-2191
Practice Address - Street 1:1001 W 10TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2859
Practice Address - Country:US
Practice Address - Phone:317-630-7525
Practice Address - Fax:317-567-2191
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042739A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200136450Medicaid
ING03699Medicare UPIN
IN248340UMedicare PIN