Provider Demographics
NPI:1043229727
Name:WALL, JOHN W (DPM)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:WALL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
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Mailing Address - Street 1:1411 W OLIVE AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91506-2427
Mailing Address - Country:US
Mailing Address - Phone:818-846-4122
Mailing Address - Fax:818-848-8634
Practice Address - Street 1:1411 W OLIVE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91506-2427
Practice Address - Country:US
Practice Address - Phone:818-846-4122
Practice Address - Fax:818-848-8634
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2008-10-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAE1369213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE1369Medicare PIN
CA4711140001Medicare NSC
CAT10918Medicare UPIN
CAE1369AMedicare ID - Type Unspecified