Provider Demographics
NPI:1710909064
Name:WALLS III, GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:WALLS III
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 1:123 N MAIN
Mailing Address - Street 2:
Mailing Address - City:LONE STAR
Mailing Address - State:TX
Mailing Address - Zip Code:75668
Mailing Address - Country:US
Mailing Address - Phone:903-656-8613
Mailing Address - Fax:
Practice Address - Street 1:123 N MAIN
Practice Address - Street 2:
Practice Address - City:LONE STAR
Practice Address - State:TX
Practice Address - Zip Code:75668
Practice Address - Country:US
Practice Address - Phone:903-656-8613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL31782083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXI69153Medicare UPIN
TX8J2344Medicare PIN