Healthcare Provider Details

I. General information

NPI: 1902291446
Provider Name (Legal Business Name): HEIDI WALLS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2015
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 VERANDA ST
PORTLAND ME
04103-5545
US

IV. Provider business mailing address

PO BOX 9746
PORTLAND ME
04104-5040
US

V. Phone/Fax

Practice location:
  • Phone: 207-828-2402
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD22437
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: