Provider Demographics
NPI:1710921291
Name:WALL, RAYMOND LOUIS (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:LOUIS
Last Name:WALL
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 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:SUITE 280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:405-425-8100
Mailing Address - Fax:405-425-8109
Practice Address - Street 1:1600 SW 119TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-4908
Practice Address - Country:US
Practice Address - Phone:405-425-8100
Practice Address - Fax:405-425-8109
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15347207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E16484Medicare UPIN
900522214Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
243435104Medicare ID - Type Unspecified