Provider Demographics
NPI:1760487276
Name:WALL, SCOT A (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOT
Middle Name:A
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 1:2304 ROSEMONT CT
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31721-9110
Mailing Address - Country:US
Mailing Address - Phone:229-888-5023
Mailing Address - Fax:
Practice Address - Street 1:2304 ROSEMONT CT
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31721-9110
Practice Address - Country:US
Practice Address - Phone:229-888-5023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA14675207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00136529AMedicaid
0749880001Medicare NSC
$$$$$$$$$BMedicare PIN
GA00136529AMedicaid
CI4690Medicare PIN
0749880001Medicare PIN
180033549Medicare PIN
CM6672Medicare PIN
180035160Medicare PIN