Provider Demographics
NPI:1487660973
Name:WALL, ERIC MARTIN (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:MARTIN
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:PO BOX 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:206-543-6420
Mailing Address - Fax:
Practice Address - Street 1:2505 2ND AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98121-1452
Practice Address - Country:US
Practice Address - Phone:206-443-0400
Practice Address - Fax:206-520-1599
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14497207Q00000X
WAMD00018314207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1006220Medicaid
OR137919Medicaid
WA0236941OtherL&I
A28806Medicare UPIN
WA1006220Medicaid