Healthcare Provider Details

I. General information

NPI: 1932383593
Provider Name (Legal Business Name): MICHAEL A WALLS IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 12/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3399 STRAUSS AVE SUITE 219
INDIAN HEAD MD
20640-5164
US

IV. Provider business mailing address

3399 STRAUSS AVE SUITE 219
INDIAN HEAD MD
20640-5164
US

V. Phone/Fax

Practice location:
  • Phone: 301-744-2055
  • Fax: 301-744-1028
Mailing address:
  • Phone: 301-744-2055
  • Fax: 301-744-1028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: