Healthcare Provider Details

I. General information

NPI: 1346446671
Provider Name (Legal Business Name): ALLISON PAULK WALL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2007
Last Update Date: 07/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 BROAD AVE SUITE 270
GULFPORT MS
39501-2404
US

IV. Provider business mailing address

PO BOX 1810
GULFPORT MS
39502-1810
US

V. Phone/Fax

Practice location:
  • Phone: 228-575-1234
  • Fax: 228-575-1230
Mailing address:
  • Phone: 228-575-1234
  • Fax: 228-575-1240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number20162
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: