Provider Demographics
NPI:1073643920
Name:WALLS, EMERSON BERTRAM (DO)
Entity Type:Individual
Prefix:DR
First Name:EMERSON
Middle Name:BERTRAM
Last Name:WALLS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 N FRESNO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93703-3845
Mailing Address - Country:US
Mailing Address - Phone:559-495-6758
Mailing Address - Fax:559-495-6784
Practice Address - Street 1:1300 N FRESNO ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-3845
Practice Address - Country:US
Practice Address - Phone:559-495-6758
Practice Address - Fax:559-495-6784
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5923208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A5923OtherDO LICENSE