Provider Demographics
NPI:1760410187
Name:WALLER, THOMAS A (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:A
Last Name:WALLER
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 1:6300 W PARKER RD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-8100
Mailing Address - Country:US
Mailing Address - Phone:469-800-4400
Mailing Address - Fax:469-800-4410
Practice Address - Street 1:6300 W PARKER RD
Practice Address - Street 2:SUITE 125
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-8100
Practice Address - Country:US
Practice Address - Phone:469-800-4400
Practice Address - Fax:469-800-4410
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2407207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX118387304Medicaid
TX8CX368OtherBCBSTX
TX118387308Medicaid
TX118387307Medicaid
TX118387306Medicaid
TXP00989258Medicare PIN
TX118387306Medicaid
TX060065991Medicare PIN
TX060065992Medicare PIN
TX8740N7Medicare PIN
TX060065990Medicare PIN
TX8CX368OtherBCBSTX
TX118387304Medicaid
TXTXB138354Medicare PIN