Provider Demographics
NPI:1790712792
Name:WALL, BRYAN T (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:T
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 1:18444 N 25TH AVE
Mailing Address - Street 2:STE 310
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-1266
Mailing Address - Country:US
Mailing Address - Phone:623-537-5600
Mailing Address - Fax:866-939-2673
Practice Address - Street 1:18444 N 25TH AVE
Practice Address - Street 2:STE 210
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-1264
Practice Address - Country:US
Practice Address - Phone:623-537-5600
Practice Address - Fax:866-939-2673
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36177207X00000X, 207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ5550830006OtherMEDICARE NSC ANTHEM
AZ5550830008OtherMEDICARE NSC SWV
AZ5550830009OtherMEDICARE NSC AZ NORTH
AZ5550830007OtherMEDICARE NSC DV
AZ5550830010OtherMEDICARE NSC GILBERT
AZP00618125OtherRR MEDICARE
AZ5550830003OtherMEDICARE NSC PEORIA
AZ159666Medicaid
AZ5550830001OtherMEDICARE NSC SCW
AZ5550830004OtherMEDICARE NSC PV
AZ159666Medicaid