Healthcare Provider Details

I. General information

NPI: 1154423754
Provider Name (Legal Business Name): BERT PUCKETT WALL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

526 COLLEGE DR
BARNESVILLE GA
30204-1713
US

IV. Provider business mailing address

526 COLLEGE DR
BARNESVILLE GA
30204-1713
US

V. Phone/Fax

Practice location:
  • Phone: 770-358-3284
  • Fax: 770-358-1015
Mailing address:
  • Phone: 770-358-3284
  • Fax: 770-358-1015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number048003
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: