Healthcare Provider Details

I. General information

NPI: 1518921238
Provider Name (Legal Business Name): KENNETH WILLIAM WALLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 EMANCIPATION DR
HAMPTON VA
23667-0001
US

IV. Provider business mailing address

100 EMANCIPATION DR
HAMPTON VA
23667-0001
US

V. Phone/Fax

Practice location:
  • Phone: 757-722-9961
  • Fax: 757-726-6078
Mailing address:
  • Phone: 757-722-9961
  • Fax: 757-726-6078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License Number0101040108
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number0101040108
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: