1538264064 NPI number — DAVID GWALTNEY M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538264064 NPI number — DAVID GWALTNEY M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

GWALTNEY

Provider First Name:

DAVID

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1538264064

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

01/30/2025

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

2333 KNOB CREEK RD STE 16

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

JOHNSON CITY

Provider Business Mailing Address State Name:

TN

Provider Business Mailing Address Postal Code:

37604-2007

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

423-975-0764

Provider Business Mailing Address Fax Number:

423-975-0141

Provider First Line Business Practice Location Address:

1 MEDICAL PARK BLVD

Provider Second Line Business Practice Location Address:

250 WEST

Provider Business Practice Location Address City Name:

BRISTOL

Provider Business Practice Location Address State Name:

TN

Provider Business Practice Location Address Postal Code:

37620-7430

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

423-844-3919

Provider Business Practice Location Address Fax Number:

423-975-0141

Provider Enumeration Date:

09/13/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 208600000X , with the licence number:  15402 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 0636398 . This is a "UMWA GROUP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: 022276800 . This is a "BLACK LUNG GROUP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: F03906748 . This is a "CHAMPUS GROUP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: TN0102 . This is a "JOHN DEERE NOW UNITED HC" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: 2001924 . This is a "BCBS OF TENNESSEE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: 027541 . This is a "INDV ANTHEM/GROUP #093410" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: 3008207 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
• Identifier: 4546155 . This is a "AETNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: 7300140000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
• Identifier: 7304692 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
• Identifier: 770000847 . This is a "MCRAILROAD/GROUP#CA8128" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".