Provider Demographics
NPI:1003668328
Name:WALL DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:WALL DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WESTON
Authorized Official - Middle Name:
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-432-3225
Mailing Address - Street 1:2476 DELPHI CIR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33812-5241
Mailing Address - Country:US
Mailing Address - Phone:727-432-3225
Mailing Address - Fax:
Practice Address - Street 1:1700 66TH ST N STE 300
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-5500
Practice Address - Country:US
Practice Address - Phone:727-432-3225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty