Provider Demographics
NPI:1619904448
Name:WALTON, RICHARAD ALLYN JR (PHD)
Entity type:Individual
Prefix:DR
First Name:RICHARAD
Middle Name:ALLYN
Last Name:WALTON
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5110 S YALE AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-7401
Mailing Address - Country:US
Mailing Address - Phone:918-779-7637
Mailing Address - Fax:918-938-6037
Practice Address - Street 1:5110 S YALE AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-7401
Practice Address - Country:US
Practice Address - Phone:918-779-7637
Practice Address - Fax:918-938-6037
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2008-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK508103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100840000AMedicaid