MEDICARE: DR. TOMI LEE WALL 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
1	207NS0135X	Procedural Dermatology Physician	A97586	CA
2	207N00000X	Dermatology Physician	A97586	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	462225	OTHER	MA	TUFTS HEALTH PLAN
2	J29028	OTHER	MA	BCBS MA

General Provider Information

NPI Number	:	1417947060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TOMI LEE WALL MD

Provider Business Mailing Address
First Line	:	3300 WEBSTER ST STE 1106
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94609-3125
Country	:	US
Telephone Number	:	510-763-2662
Fax Number	:

Provider Business Practice Location Address
First Line	:	3300 WEBSTER ST
Second Line	:	SUITE 1106
City	:	OAKLAND
State	:	CA
Zip	:	94609-3117
Country	:	US
Telephone Number	:	510-763-2662
Fax Number	:	510-601-0750

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2005
Last Update Date	:	07/11/2007

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