Provider Demographics
NPI:1568705879
Name:WALLER, TRAVIS (MD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:WALLER
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 1:4701 STAGGERBRUSH RD
Mailing Address - Street 2:APT. 1324
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-4401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 FARENHOLT AVENUE
Practice Address - Street 2:
Practice Address - City:TUTUHAN
Practice Address - State:GUAM
Practice Address - Zip Code:96910
Practice Address - Country:UM
Practice Address - Phone:671-864-2967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-04
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUM-2105208000000X
390200000X
MO2014023894208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program