Provider Demographics
NPI:1467454462
Name:WALL, STEPHEN JAY (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:JAY
Last Name:WALL
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 1:15 FACILITY DR
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:NC
Mailing Address - Zip Code:28721-9438
Mailing Address - Country:US
Mailing Address - Phone:828-452-2211
Mailing Address - Fax:828-452-4421
Practice Address - Street 1:15 FACILITY DR
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:NC
Practice Address - Zip Code:28721-9438
Practice Address - Country:US
Practice Address - Phone:828-452-2211
Practice Address - Fax:828-452-4421
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC382342080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1270239OtherUNITED HEALTHCARE
NC8985406Medicaid
1270239OtherUNITED HEALTHCARE
NC8985406Medicaid