Provider Demographics
NPI:1609925874
Name:WALLNER, RICHARD LEE (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:LEE
Last Name:WALLNER
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 1:2715 BOLTON BOONE
Mailing Address - Street 2:SUITE A
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115
Mailing Address - Country:US
Mailing Address - Phone:972-296-0086
Mailing Address - Fax:972-298-5536
Practice Address - Street 1:2715 BOLTON BOONE
Practice Address - Street 2:SUITE A
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115
Practice Address - Country:US
Practice Address - Phone:972-296-0086
Practice Address - Fax:972-298-5536
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF7283207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00FH64OtherBCBS
B27868Medicare UPIN
00FH64Medicare ID - Type Unspecified