Provider Demographics
NPI:1679579791
Name:WALLS, MICHAEL JAMES (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:WALLS
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:PO BOX 95533
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76099-9703
Mailing Address - Country:US
Mailing Address - Phone:936-520-8983
Mailing Address - Fax:936-463-6508
Practice Address - Street 1:4015 I 45 N STE 310
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-5077
Practice Address - Country:US
Practice Address - Phone:936-520-8983
Practice Address - Fax:936-463-6508
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6047174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX102913404Medicaid
TXF86785Medicare UPIN
TX102913404Medicaid