Healthcare Provider Details

I. General information

NPI: 1053334219
Provider Name (Legal Business Name): ANDREW WALLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 VALLEY ST NE
ABINGDON VA
24210-2912
US

IV. Provider business mailing address

300 VALLEY ST NE
ABINGDON VA
24210-2912
US

V. Phone/Fax

Practice location:
  • Phone: 276-206-8197
  • Fax: 276-206-8761
Mailing address:
  • Phone: 276-206-8197
  • Fax: 276-206-8761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number0101257630
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101257630
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: