Provider Demographics
NPI:1063678894
Name:MICHAEL N WALL, MD
Entity Type:Organization
Organization Name:MICHAEL N WALL, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:N
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-558-6288
Mailing Address - Street 1:PO BOX 1606
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78296-1606
Mailing Address - Country:US
Mailing Address - Phone:210-558-6299
Mailing Address - Fax:210-558-6289
Practice Address - Street 1:4085 DE ZAVALA RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SHAVANO PARK
Practice Address - State:TX
Practice Address - Zip Code:78249-2084
Practice Address - Country:US
Practice Address - Phone:210-558-6288
Practice Address - Fax:210-558-6289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-31
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1227207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX035387201Medicaid
TX00PR62Medicare PIN