Provider Demographics
NPI:1326043373
Name:WALLEN, NEIL D (MD)
Entity Type:Individual
Prefix:DR
First Name:NEIL
Middle Name:D
Last Name:WALLEN
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:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-844-7000
Mailing Address - Fax:423-844-7007
Practice Address - Street 1:933 HIGHWAY 126
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-3310
Practice Address - Country:US
Practice Address - Phone:423-844-7000
Practice Address - Fax:423-844-7007
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2009-09-24
Deactivation Date:2006-03-18
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
TNMD0000017754207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1326043373Medicaid
VA006002188Medicaid
TN1510634Medicaid
TN3032572Medicaid
TNA99617Medicare UPIN
VA1326043373Medicaid
TN3700592Medicare PIN
TN30325722Medicare UPIN
TN30325721Medicare PIN