Provider Demographics
NPI:1407216617
Name:MARK B. WALL, MD PA
Entity Type:Organization
Organization Name:MARK B. WALL, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:BURNETTE
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-875-0693
Mailing Address - Street 1:202 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-4626
Mailing Address - Country:US
Mailing Address - Phone:228-875-0693
Mailing Address - Fax:
Practice Address - Street 1:150 REYNOIR ST
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39530-4130
Practice Address - Country:US
Practice Address - Phone:228-432-1571
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-01
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty