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General NPI Number Information
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NPI Number | 1992059968
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Entity Type | Organization
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Legal Business Name | SIMEON H. WALL, MD A PROFESSIONAL MEDICAL CORP
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Dates
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Enumeration Date | 10/30/2012
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Last Update Date | 10/30/2012
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Provider Practice Location Address
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Address Line | 8600 FERN AVE
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City | SHREVEPORT
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State | LA
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Zip | 71105-5639
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Country | US
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Telephone | 318-795-0801
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Fax | 318-795-9492
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Provider Business Mailing Address
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Address Line | 8600 FERN AVE
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City | SHREVEPORT
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State | LA
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Zip | 71105-5639
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Country | US
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Telephone | 318-795-0801
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Fax | 318-795-9492
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Authorized Official
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Title or Position | OWNER
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Name | DR. SIMEON HENINGER WALL SR.
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Credential | M.D.
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Telephone | 318-795-0801
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | 02970R
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License Number State | LA
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