Provider Demographics
NPI:1275677411
Name:WALLER, ADAM DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:DAVID
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 1:393 N BELAIR RD
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3096
Mailing Address - Country:US
Mailing Address - Phone:706-868-0104
Mailing Address - Fax:706-650-7825
Practice Address - Street 1:393 N BELAIR RD
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3096
Practice Address - Country:US
Practice Address - Phone:706-868-0104
Practice Address - Fax:706-650-7825
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050745207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2317Medicare ID - Type Unspecified
GAH45520Medicare UPIN