Healthcare Provider Details

I. General information

NPI: 1275522682
Provider Name (Legal Business Name): SIMEON WALL JR. MD, FACS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 04/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 FERN AVE
SHREVEPORT LA
71105-5639
US

IV. Provider business mailing address

8600 FERN AVE
SHREVEPORT LA
71105-5639
US

V. Phone/Fax

Practice location:
  • Phone: 318-795-0801
  • Fax: 318-795-9492
Mailing address:
  • Phone: 318-795-0801
  • Fax: 318-795-9492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number14159R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: