Provider Demographics
NPI:1710982129
Name:WALLS, BRYAN DEAN (DO)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:DEAN
Last Name:WALLS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2306 SE 39TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-5918
Mailing Address - Country:US
Mailing Address - Phone:503-963-9181
Mailing Address - Fax:503-963-9182
Practice Address - Street 1:2306 SE 39TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-5918
Practice Address - Country:US
Practice Address - Phone:503-963-9181
Practice Address - Fax:503-963-9182
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO20625207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR104668Medicare PIN
ORH01965Medicare UPIN