Provider Demographics
NPI:1154472462
Name:WALLER, PAUL ALBERTO (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:ALBERTO
Last Name:WALLER
Suffix:
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 1:8350 ARBOR SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-5000
Mailing Address - Country:US
Mailing Address - Phone:513-346-3888
Mailing Address - Fax:513-229-8310
Practice Address - Street 1:8350 ARBOR SQUARE DR
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-5000
Practice Address - Country:US
Practice Address - Phone:513-346-3888
Practice Address - Fax:513-229-8310
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35058185207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHF02600Medicare UPIN