1447288808 NPI number — JEFFREY A WALL D.O.

Table of content: JEFFREY A WALL D.O. (NPI 1447288808)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447288808 NPI number — JEFFREY A WALL D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALL
Provider First Name:
JEFFREY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447288808
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
190 STETSON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUBURN
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04210-7813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-784-7388
Provider Business Mailing Address Fax Number:
207-795-2043

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
190 STETSON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04210-7813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-784-7388
Provider Business Practice Location Address Fax Number:
207-795-2043
Provider Enumeration Date:
06/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  1877 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 048350 . This is a "ANTHEM" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 9386763 . This is a "PHCS" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 9759878 . This is a "CIGNA" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 3769958 . This is a "AETNA" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 431799199 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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