Healthcare Provider Details

I. General information

NPI: 1821001041
Provider Name (Legal Business Name): RICHARD EDWIN WALLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 03/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 MARTIN LUTHER KING DRIVE
MARKS MS
38646-0289
US

IV. Provider business mailing address

PO BOX 289
MARKS MS
38646-0289
US

V. Phone/Fax

Practice location:
  • Phone: 662-326-3502
  • Fax: 662-326-2555
Mailing address:
  • Phone: 662-326-3500
  • Fax: 662-326-7077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number07067
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: