Provider Demographics
NPI:1508866237
Name:WALLS, BRIAN BOLIVAR (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:BOLIVAR
Last Name:WALLS
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 540033
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32954-0033
Mailing Address - Country:US
Mailing Address - Phone:321-243-8593
Mailing Address - Fax:321-453-6280
Practice Address - Street 1:500 CROCKETT BLVD
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-5034
Practice Address - Country:US
Practice Address - Phone:321-243-8593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71812207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251358700Medicaid
FL32508Medicare PIN
FL251358700Medicaid