Provider Demographics
NPI:1467601096
Name:BRYAN D. WALLS, D.O. P.C.
Entity Type:Organization
Organization Name:BRYAN D. WALLS, D.O. P.C.
Other - Org Name:HAWTHORNE FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:WALLS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:503-963-9181
Mailing Address - Street 1:2306 SE 39TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-5918
Mailing Address - Country:US
Mailing Address - Phone:503-963-9181
Mailing Address - Fax:503-963-9182
Practice Address - Street 1:2306 SE 39TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-5918
Practice Address - Country:US
Practice Address - Phone:503-963-9181
Practice Address - Fax:503-963-9182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-18
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO20625207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORH01965Medicare UPIN