Provider Demographics
NPI:1639118730
Name:WALL, MICHAEL N (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:N
Last Name:WALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1606
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78296-1606
Mailing Address - Country:US
Mailing Address - Phone:210-558-3628
Mailing Address - Fax:210-558-6289
Practice Address - Street 1:4085 DE ZAVALA RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SHAVANO PARK
Practice Address - State:TX
Practice Address - Zip Code:78249-2084
Practice Address - Country:US
Practice Address - Phone:210-558-6288
Practice Address - Fax:210-558-6289
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXG1227207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX035387201Medicaid
TX00PR62Medicare PIN