Healthcare Provider Details

I. General information

NPI: 1760487276
Provider Name (Legal Business Name): SCOT A WALL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 04/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2304 ROSEMONT CT
ALBANY GA
31721-9110
US

IV. Provider business mailing address

2304 ROSEMONT CT
ALBANY GA
31721-9110
US

V. Phone/Fax

Practice location:
  • Phone: 229-888-5023
  • Fax:
Mailing address:
  • Phone: 229-888-5023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number14675
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: