Provider Demographics
NPI:1518966688
Name:WALLER, DAVID F (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:F
Last Name:WALLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4868 BRIDGE RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-2048
Mailing Address - Country:US
Mailing Address - Phone:757-483-7100
Mailing Address - Fax:757-483-7150
Practice Address - Street 1:4868 BRIDGE RD
Practice Address - Street 2:SUITE 300
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-2048
Practice Address - Country:US
Practice Address - Phone:757-483-7100
Practice Address - Fax:757-483-7150
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2013-07-22
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Provider Licenses
StateLicense IDTaxonomies
VA0101047125207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005623260Medicaid
VAF30480Medicare UPIN
VA005623260Medicaid