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General NPI Number Information
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NPI Number | 1891165023
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Entity Type | Organization
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Legal Business Name | BRIAN B WALLS MD PLLC
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Dates
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Enumeration Date | 09/30/2015
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Last Update Date | 05/22/2017
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Provider Practice Location Address
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Address Line | 500 CROCKETT BLVD
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City | MERRITT ISLAND
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State | FL
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Zip | 32953-5034
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Country | US
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Telephone | 321-243-8593
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Fax | 321-454-2523
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Provider Business Mailing Address
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Address Line | PO BOX 540033
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City | MERRITT ISLAND
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State | FL
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Zip | 32954-0033
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Country | US
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Telephone | 321-243-8593
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Fax | 321-454-2325
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Authorized Official
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Title or Position | PHYSICIAN / OWNER
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Name | DR. BRIAN B WALLS
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Credential | MD
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Telephone | 321-243-8593
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | ME71812
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License Number State | FL
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