Provider Demographics
NPI:1750449971
Name:WALLS, WILLIAM L (BOCO, CPED, CO,OPA-C)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:L
Last Name:WALLS
Suffix:
Gender:M
Credentials:BOCO, CPED, CO,OPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 COMMERCE ST W
Mailing Address - Street 2:
Mailing Address - City:PINEVIEW
Mailing Address - State:GA
Mailing Address - Zip Code:31071-3145
Mailing Address - Country:US
Mailing Address - Phone:229-624-2723
Mailing Address - Fax:478-953-2927
Practice Address - Street 1:110 OSIGIAN BLVD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-7880
Practice Address - Country:US
Practice Address - Phone:478-953-2922
Practice Address - Fax:478-953-2927
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000009174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1895OtherCERTIFIED PEDORTHIST
GA681OtherORTHOPEDIC PHYS ASSISTANT
GAC15148OtherBOC CERTIFIED ORTHOTIST
GACO3593OtherABC CERTIFIED ORTHOTIST
GA714OtherPARAMEDIC
GA000009OtherSTATE LICENSED ORTHOTIST