Healthcare Provider Details

I. General information

NPI: 1124373501
Provider Name (Legal Business Name): ALICIA REGINA WALLS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2012
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17520 W GRAND PKWY S STE 120
SUGAR LAND TX
77479-4759
US

IV. Provider business mailing address

14960 PARK ROW DR
HOUSTON TX
77084-5165
US

V. Phone/Fax

Practice location:
  • Phone: 281-298-1144
  • Fax: 281-298-1133
Mailing address:
  • Phone: 281-298-1144
  • Fax: 281-297-1133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberP5755
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License NumberP5755
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: