Healthcare Provider Details

I. General information

NPI: 1568705879
Provider Name (Legal Business Name): TRAVIS WALLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2013
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL HOSPITAL YOKOSUKA
YOKOSUKA JAPAN
96350
JP

IV. Provider business mailing address

PSC 475 BOX 1
FPO AP
96350-1200
US

V. Phone/Fax

Practice location:
  • Phone: 936-552-6503
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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 Code208000000X
TaxonomyPediatrics Physician
License Number2014023894
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM-2105
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: