Healthcare Provider Details

I. General information

NPI: 1073643920
Provider Name (Legal Business Name): EMERSON BERTRAM WALLS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 06/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N FRESNO ST
FRESNO CA
93703-3845
US

IV. Provider business mailing address

1300 N FRESNO ST
FRESNO CA
93703-3845
US

V. Phone/Fax

Practice location:
  • Phone: 559-495-6758
  • Fax: 559-495-6784
Mailing address:
  • Phone: 559-495-6758
  • Fax: 559-495-6784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20A5923
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: