Healthcare Provider Details

I. General information

NPI: 1053007021
Provider Name (Legal Business Name): THOMAS EDWIN WALL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2023
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOSPITAL DR
COLUMBIA MO
65212-1000
US

IV. Provider business mailing address

1 HOSPITAL DR
COLUMBIA MO
65212-1000
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-4209
  • Fax: 573-882-8668
Mailing address:
  • Phone: 573-882-4209
  • Fax: 573-882-8668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: