Provider Demographics
NPI:1083888325
Name:WALLS, MICHAEL JASON (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JASON
Last Name:WALLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 21890
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4115
Mailing Address - Country:US
Mailing Address - Phone:502-907-0356
Mailing Address - Fax:502-919-9780
Practice Address - Street 1:320 THOMAS MORE PKWY
Practice Address - Street 2:SUITE 202
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3410
Practice Address - Country:US
Practice Address - Phone:859-331-0432
Practice Address - Fax:859-331-0956
Is Sole Proprietor?:No
Enumeration Date:2008-04-17
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY42678208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
9318357OtherAETNA PIN
CS1811400200OtherCARESOURCE ID
KY7100086870Medicaid
000001148521OtherANTHEM ID
OH0295938Medicaid
IN300012365Medicaid
003031812OtherUNITED HEALTHCARE PROVIDER ID NUMBER
KY15725575OtherWELLCARE OF KENTUCKY PROVIDER ID NUMBER
KY298418KYIPOtherAETNA BETTER HEALTH OF KENTUCKY PROVIDER ID NUMBER
KYP02011197OtherRAILROAD MEDICARE