Provider Demographics
NPI:1427037001
Name:WALLER, JOHN ARTHUR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ARTHUR
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 1:1708 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HEBER SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72543-2823
Mailing Address - Country:US
Mailing Address - Phone:501-362-6631
Mailing Address - Fax:
Practice Address - Street 1:1708 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HEBER SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72543-2823
Practice Address - Country:US
Practice Address - Phone:501-362-6631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR4651207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR140217001Medicaid
ARD23380Medicare UPIN
AR140217001Medicaid