Provider Demographics
NPI:1609433796
Name:WALLER, BRADLEY B (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:B
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 1:206 N ARCADE ST
Mailing Address - Street 2:
Mailing Address - City:MAQUOKETA
Mailing Address - State:IA
Mailing Address - Zip Code:52060-2022
Mailing Address - Country:US
Mailing Address - Phone:563-652-6711
Mailing Address - Fax:563-652-6715
Practice Address - Street 1:206 N ARCADE ST
Practice Address - Street 2:
Practice Address - City:MAQUOKETA
Practice Address - State:IA
Practice Address - Zip Code:52060-2022
Practice Address - Country:US
Practice Address - Phone:563-652-6711
Practice Address - Fax:563-652-6715
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA47781207Q00000X
IAR-11492207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine