Provider Demographics
NPI:1861446130
Name:WALL, BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
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 1:1420 VICEROY DR
Mailing Address - Street 2:ATTN: LASHUNDA JOHNSON
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-2208
Mailing Address - Country:US
Mailing Address - Phone:214-358-2300
Mailing Address - Fax:214-366-6127
Practice Address - Street 1:13154 COIT RD
Practice Address - Street 2:STE 100
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-5773
Practice Address - Country:US
Practice Address - Phone:214-358-2300
Practice Address - Fax:214-366-6430
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXG1312207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4072827OtherAETNA #
TX2323106OtherBCBS BLUELINK #
LA1912239OtherLOUISIANA MCD #
TX2323106OtherBCBS BLUELINK #
TXC23106Medicare UPIN