Healthcare Provider Details

I. General information

NPI: 1043229727
Provider Name (Legal Business Name): JOHN W WALL D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 10/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 W OLIVE AVE SUITE C
BURBANK CA
91506-2427
US

IV. Provider business mailing address

1411 W OLIVE AVE SUITE C
BURBANK CA
91506-2427
US

V. Phone/Fax

Practice location:
  • Phone: 818-846-4122
  • Fax: 818-848-8634
Mailing address:
  • Phone: 818-846-4122
  • Fax: 818-848-8634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE1369
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: