Provider Demographics
NPI:1275522682
Name:WALL, SIMEON JR (MD, FACS)
Entity Type:Individual
Prefix:
First Name:SIMEON
Middle Name:
Last Name:WALL
Suffix:JR
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8600 FERN AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5639
Mailing Address - Country:US
Mailing Address - Phone:318-795-0801
Mailing Address - Fax:318-795-9492
Practice Address - Street 1:8600 FERN AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5639
Practice Address - Country:US
Practice Address - Phone:318-795-0801
Practice Address - Fax:318-795-9492
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14159R2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1184292Medicaid
4A494Medicare ID - Type Unspecified
LA1184292Medicaid