Provider Demographics
NPI:1265494314
Name:WALLER, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WALLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1611 S UTICA AVE
Mailing Address - Street 2:STE 217
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4909
Mailing Address - Country:US
Mailing Address - Phone:918-744-3664
Mailing Address - Fax:918-748-7688
Practice Address - Street 1:1611 S UTICA AVE
Practice Address - Street 2:STE 217
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4909
Practice Address - Country:US
Practice Address - Phone:918-744-3664
Practice Address - Fax:918-748-7688
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK18067207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP00370953OtherRR MEDICARE
OK100031900AMedicaid
OK100031900AMedicaid
OKF72671Medicare UPIN