Provider Demographics
NPI:1376778258
Name:WALLER, JOSEPH G (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:G
Last Name:WALLER
Suffix:
Gender:M
Credentials:MD, MPH
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 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-2551
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1475 KISKER RD STE 180
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63304-8786
Practice Address - Country:US
Practice Address - Phone:636-442-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-21
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0793842085R0001X
KS04-372032085R0001X
MO20140139232085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology