Healthcare Provider Details

I. General information

NPI: 1962480970
Provider Name (Legal Business Name): SUSAN DALE WALL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 WESTBURY DR STE 2
IOWA CITY IA
52245-2727
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 319-339-3872
  • Fax: 319-339-3874
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number28400
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number28400
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: