Provider Demographics
NPI:1568465177
Name:WALLER-NIEWOLD, MARILYN J (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:J
Last Name:WALLER-NIEWOLD
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:MARILYN
Other - Middle Name:J
Other - Last Name:WALLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:1270 KOT-NUM ROAD, BOX 1209
Mailing Address - Street 2:
Mailing Address - City:WARM SPRINGS
Mailing Address - State:OR
Mailing Address - Zip Code:98861
Mailing Address - Country:US
Mailing Address - Phone:541-553-1196
Mailing Address - Fax:541-553-2613
Practice Address - Street 1:1270 KOT-NUM ROAD, BOX 1209
Practice Address - Street 2:
Practice Address - City:WARM SPRINGS
Practice Address - State:OR
Practice Address - Zip Code:98861
Practice Address - Country:US
Practice Address - Phone:541-553-1196
Practice Address - Fax:541-553-2613
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00352213ES0103X
CAE3808213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0407825Medicaid
OR273855Medicaid
CA0407825Medicaid
OR273855Medicaid