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NPI Code Detail

MEDICARE: WILLIAM LOWE WALLER III MD

MEDICARE: WILLIAM LOWE WALLER III MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207N00000XDermatology PhysicianMD.201654LA
2207N00000XDermatology Physician21371MS

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
19789697OTHERMSAETNA
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1053592840
Entity Type Code : Individual
Provider Name (Legal Business Name) : WILLIAM LOWE WALLER III MD
Provider Business Mailing Address
First Line : 415 S 28TH AVE
Second Line :
City : HATTIESBURG
State : MS
Zip : 39401-7246
Country : US
Telephone Number : 601-579-3130
Fax Number : 601-579-5240
Provider Business Practice Location Address
First Line : 3 THOMPSON PARK
Second Line :
City : HATTIESBURG
State : MS
Zip : 39401-8202
Country : US
Telephone Number : 601-579-3130
Fax Number : 601-264-5092
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/20/2007
Last Update Date : 08/03/2020

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Directions to “ WILLIAM LOWE WALLER III MD” Practice Location

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