MEDICARE: IAN WALL D.O.

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	207R00000X	Internal Medicine Physician	240806-1	NY

General Provider Information

NPI Number	:	1528170792
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IAN WALL D.O.

Provider Business Mailing Address
First Line	:	902 QUENTIN RD
Second Line	:	SEVENTH FLOOR
City	:	BROOKLYN
State	:	NY
Zip	:	11223-2214
Country	:	US
Telephone Number	:	718-336-3900
Fax Number	:	718-336-3990

Provider Business Practice Location Address
First Line	:	902 QUENTIN RD
Second Line	:	SEVENTH FLOOR
City	:	BROOKLYN
State	:	NY
Zip	:	11223-2214
Country	:	US
Telephone Number	:	718-336-3900
Fax Number	:	718-336-3990

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	05/30/2014

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