Provider Demographics
NPI:1639292832
Name:WALLER, CATHERINE ANN (MD)
Entity Type:Individual
Prefix:MRS
First Name:CATHERINE
Middle Name:ANN
Last Name:WALLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5757 PAINT VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48306-2466
Mailing Address - Country:US
Mailing Address - Phone:248-656-3175
Mailing Address - Fax:
Practice Address - Street 1:1854 W AUBURN RD
Practice Address - Street 2:STE. 400
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-3868
Practice Address - Country:US
Practice Address - Phone:248-844-1414
Practice Address - Fax:248-844-2670
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301047652174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIAW2879875OtherDEA
MIAW2879875OtherDEA