Provider Demographics
NPI:1629057609
Name:WALLER, STEPHEN GLENN (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:GLENN
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 1:232 COLLEGE BLVD
Mailing Address - Street 2:
Mailing Address - City:ALAMO HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:78209-4517
Mailing Address - Country:US
Mailing Address - Phone:210-829-5575
Mailing Address - Fax:
Practice Address - Street 1:2200 BERGQUIST DR
Practice Address - Street 2:SUITE 1
Practice Address - City:LACKLAND A F B
Practice Address - State:TX
Practice Address - Zip Code:78236-9907
Practice Address - Country:US
Practice Address - Phone:210-292-6583
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0303207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology