Healthcare Provider Details

I. General information

NPI: 1700346830
Provider Name (Legal Business Name): CAMERON BRADLEY WALLER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2019
Last Update Date: 08/16/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 MARY STREET
EVANSVILLE IN
47747-1972
US

IV. Provider business mailing address

PO BOX 3366
EVANSVILLE IN
47732-3366
US

V. Phone/Fax

Practice location:
  • Phone: 812-450-2240
  • Fax: 812-450-2710
Mailing address:
  • Phone: 812-450-6815
  • Fax: 812-450-6822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number02006682A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: