Provider Demographics
NPI:1760946594
Name:WALLS, JOHN C
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:C
Last Name:WALLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 CHERRY LANE
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801
Mailing Address - Country:US
Mailing Address - Phone:516-733-7000
Mailing Address - Fax:
Practice Address - Street 1:31 EAST MONTAUK HIGHWAY
Practice Address - Street 2:
Practice Address - City:HAMPTON BAYS
Practice Address - State:NY
Practice Address - Zip Code:11946-0701
Practice Address - Country:US
Practice Address - Phone:631-723-3362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program