Provider Demographics
NPI:1275525388
Name:WALL, RICHARD A JR (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:WALL
Suffix:JR
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:PO BOX 388
Mailing Address - Street 2:
Mailing Address - City:FISHERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22939-0388
Mailing Address - Country:US
Mailing Address - Phone:540-258-1700
Mailing Address - Fax:540-258-1800
Practice Address - Street 1:730 MCCULLOCH ST
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:VA
Practice Address - Zip Code:24555-2710
Practice Address - Country:US
Practice Address - Phone:540-258-1700
Practice Address - Fax:540-258-1800
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC24491207Q00000X
VA0101268996207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC244916Medicaid
SCI34737Medicare UPIN
SCAA09707436Medicare PIN