MEDICARE: DR. BRYAN DEAN WALLS D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	DO20625	OR

General Provider Information

NPI Number	:	1710982129
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRYAN DEAN WALLS D.O.

Provider Business Mailing Address
First Line	:	2306 SE 39TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-5918
Country	:	US
Telephone Number	:	503-963-9181
Fax Number	:	503-963-9182

Provider Business Practice Location Address
First Line	:	2306 SE 39TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-5918
Country	:	US
Telephone Number	:	503-963-9181
Fax Number	:	503-963-9182

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2005
Last Update Date	:	09/18/2008

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