Provider Demographics
NPI:1053447268
Name:WALL, MARK BURNETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:BURNETTE
Last Name:WALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:P O BOX 604
Mailing Address - Street 2:135 MAIN ST
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39530
Mailing Address - Country:US
Mailing Address - Phone:228-731-7114
Mailing Address - Fax:
Practice Address - Street 1:150 REYNOIR ST
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39530-4130
Practice Address - Country:US
Practice Address - Phone:228-436-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-24
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1020122085R0202X
AL000257732085R0202X
MS201612085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology