Provider Demographics
NPI:1548265838
Name:AUSTIN, WALTER KENNETH JR (MD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:KENNETH
Last Name:AUSTIN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:175 SAMARITAN DR STE 100
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143-1964
Mailing Address - Country:US
Mailing Address - Phone:706-253-4633
Mailing Address - Fax:706-253-1192
Practice Address - Street 1:175 SAMARITAN DR
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-1964
Practice Address - Country:US
Practice Address - Phone:706-253-4633
Practice Address - Fax:706-253-1192
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047049207RC0000X, 261QF0400X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000818639DEGMedicaid
C82652Medicare UPIN
GA202I061099Medicare PIN