Provider Demographics
NPI:1073717955
Name:WALL, CHARLES EDWARD JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:EDWARD
Last Name:WALL
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-2163
Mailing Address - Country:US
Mailing Address - Phone:662-615-3800
Mailing Address - Fax:
Practice Address - Street 1:102 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759
Practice Address - Country:US
Practice Address - Phone:662-615-3800
Practice Address - Fax:662-615-3807
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19801208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL511-65666OtherBCBS
AL102I029294OtherMEDICARE
AL175531Medicaid
7453952OtherAETNA