Healthcare Provider Details

I. General information

NPI: 1114916004
Provider Name (Legal Business Name): ROBERT E. WALL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 06/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 HIGH ST SUITE 140
DENVER CO
80205-5503
US

IV. Provider business mailing address

4900 S MONACO ST STE 210
DENVER CO
80237-3487
US

V. Phone/Fax

Practice location:
  • Phone: 303-322-2240
  • Fax: 303-322-9260
Mailing address:
  • Phone: 303-322-2240
  • Fax: 303-322-9260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number20319
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: