Provider Demographics
NPI:1497864607
Name:WALLER, FRANKLIN W JR (MD)
Entity Type:Individual
Prefix:
First Name:FRANKLIN
Middle Name:W
Last Name:WALLER
Suffix:JR
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-736-8282
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:502 BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429-3037
Practice Address - Country:US
Practice Address - Phone:601-736-8282
Practice Address - Fax:601-736-8333
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15125207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS080096788OtherRAILROAD MEDICARE
MS640507572AYOtherAMERICAN ADMIN GROUP
MS00117443Medicaid
LA1582301Medicaid
MS00117443Medicaid
MS080002455Medicare PIN