Provider Demographics
NPI:1053367219
Name:GROTE, WALTON W (MD)
Entity type:Individual
Prefix:DR
First Name:WALTON
Middle Name:W
Last Name:GROTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:3396 N FUTRALL DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4057
Mailing Address - Country:US
Mailing Address - Phone:479-582-1938
Mailing Address - Fax:479-587-0484
Practice Address - Street 1:3396 N FUTRALL DR
Practice Address - Street 2:SUITE 1
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4057
Practice Address - Country:US
Practice Address - Phone:479-582-1938
Practice Address - Fax:479-587-0484
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR-4003174400000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1163100001Medicaid
AR53269Medicare ID - Type Unspecified
AR1163100001Medicaid