Provider Demographics
NPI:1346446671
Name:WALL, ALLISON PAULK (MD)
Entity Type:Individual
Prefix:DR
First Name:ALLISON
Middle Name:PAULK
Last Name:WALL
Suffix:
Gender:F
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 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1810
Mailing Address - Country:US
Mailing Address - Phone:228-575-1234
Mailing Address - Fax:228-575-1240
Practice Address - Street 1:1340 BROAD AVE
Practice Address - Street 2:SUITE 270
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2404
Practice Address - Country:US
Practice Address - Phone:228-575-1234
Practice Address - Fax:228-575-1230
Is Sole Proprietor?:No
Enumeration Date:2007-06-24
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS20162207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04183295Medicaid
MS302I835491Medicare PIN
MS04183295Medicaid