Provider Demographics
NPI:1811376411
Name:WALLS, CLINTON (MD)
Entity Type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:
Last Name:WALLS
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 1:7466 RIPETTA ST
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34240-4706
Mailing Address - Country:US
Mailing Address - Phone:239-677-0555
Mailing Address - Fax:
Practice Address - Street 1:801 E SIOUX AVE
Practice Address - Street 2:
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501-3323
Practice Address - Country:US
Practice Address - Phone:605-224-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-28
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA076987207Q00000X
FLME134419207Q00000X
FL21875390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program