Provider Demographics
NPI:1437145083
Name:WALL, WARD B JR (MD)
Entity Type:Individual
Prefix:
First Name:WARD
Middle Name:B
Last Name:WALL
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1324 LAKELAND HILLS BLVD
Mailing Address - Street 2:ATTN MEDICAL STAFF OFFICE
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-4543
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 PABLO ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-3818
Practice Address - Country:US
Practice Address - Phone:863-687-1259
Practice Address - Fax:863-284-1786
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME90509208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1497748743OtherGROUP NPI NUMBER / LRHSI
FLH04191Medicare UPIN
FL48272YMedicare PIN
FL48272OtherBCBS OF FLORIDA
FLDA5786OtherRAILROAD MEDICARE GROUP NUMBER
FL270164200Medicaid