Provider Demographics
NPI:1508179284
Name:RICHARD L WALLNER MD PA
Entity Type:Organization
Organization Name:RICHARD L WALLNER MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-296-0086
Mailing Address - Street 1:2715 BOLTON BOONE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-2078
Mailing Address - Country:US
Mailing Address - Phone:972-296-0086
Mailing Address - Fax:972-298-5536
Practice Address - Street 1:2715 BOLTON BOONE DR
Practice Address - Street 2:SUITE A
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2078
Practice Address - Country:US
Practice Address - Phone:972-296-0086
Practice Address - Fax:972-298-5536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-22
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF7283207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX033326201Medicaid