Healthcare Provider Details

I. General information

NPI: 1841546959
Provider Name (Legal Business Name): KENNETH RUSSELL WALLER III DVM, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2012
Last Update Date: 07/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 LINDEN DR ROOM 2058
MADISON WI
53706-1100
US

IV. Provider business mailing address

2015 LINDEN DR ROOM 2058
MADISON WI
53706-1100
US

V. Phone/Fax

Practice location:
  • Phone: 608-263-7656
  • Fax:
Mailing address:
  • Phone: 608-263-7656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174M00000X
TaxonomyVeterinarian
License Number6054
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code174M00000X
TaxonomyVeterinarian
License Number7379
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code174M00000X
TaxonomyVeterinarian
License Number090010797
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: