Healthcare Provider Details

I. General information

NPI: 1962481226
Provider Name (Legal Business Name): ALAN S WALLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MIMOSA DRIVE
THOMASVILLE GA
31792
US

IV. Provider business mailing address

100 MIMOSA DRIVE
THOMASVILLE GA
31792
US

V. Phone/Fax

Practice location:
  • Phone: 229-226-8881
  • Fax: 229-225-2165
Mailing address:
  • Phone: 229-226-8881
  • Fax: 229-225-2165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number018761
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number018761
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: