Healthcare Provider Details

I. General information

NPI: 1184780728
Provider Name (Legal Business Name): RICHARD J WALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 08/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 TALBOT RD S STE 460
RENTON WA
98055-5773
US

IV. Provider business mailing address

PO BOX 50010
RENTON WA
98058-5010
US

V. Phone/Fax

Practice location:
  • Phone: 425-251-5110
  • Fax: 425-793-7382
Mailing address:
  • Phone: 425-228-3440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberMD00042456
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberMD00042456
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD00042456
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: