Provider Demographics
NPI:1174694707
Name:WALTHALL, ELLEN D (MD)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:D
Last Name:WALTHALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2162 COUNTY ROAD 1403
Mailing Address - Street 2:
Mailing Address - City:LOMETA
Mailing Address - State:TX
Mailing Address - Zip Code:76853-3444
Mailing Address - Country:US
Mailing Address - Phone:417-718-5754
Mailing Address - Fax:
Practice Address - Street 1:301 JENNY GEORGE LN
Practice Address - Street 2:
Practice Address - City:SWEETWATER
Practice Address - State:TX
Practice Address - Zip Code:79556-7152
Practice Address - Country:US
Practice Address - Phone:325-236-8886
Practice Address - Fax:325-236-8861
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0343207P00000X, 207Q00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG55151Medicare UPIN