Provider Demographics
NPI:1821001041
Name:WALLER, RICHARD EDWIN (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:EDWIN
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:PO BOX 289
Mailing Address - Street 2:
Mailing Address - City:MARKS
Mailing Address - State:MS
Mailing Address - Zip Code:38646-0289
Mailing Address - Country:US
Mailing Address - Phone:662-326-3500
Mailing Address - Fax:662-326-7077
Practice Address - Street 1:1024 MARTIN LUTHER KING DRIVE
Practice Address - Street 2:
Practice Address - City:MARKS
Practice Address - State:MS
Practice Address - Zip Code:38646-0289
Practice Address - Country:US
Practice Address - Phone:662-326-3502
Practice Address - Fax:662-326-2555
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07067207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115098Medicaid
MS080000562Medicare ID - Type Unspecified
MS00115098Medicaid