Provider Demographics
NPI:1891165023
Name:BRIAN B WALLS MD PLLC
Entity Type:Organization
Organization Name:BRIAN B WALLS MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:WALLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-243-8593
Mailing Address - Street 1:PO BOX 540033
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32954-0033
Mailing Address - Country:US
Mailing Address - Phone:321-243-8593
Mailing Address - Fax:321-454-2325
Practice Address - Street 1:500 CROCKETT BLVD
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-5034
Practice Address - Country:US
Practice Address - Phone:321-243-8593
Practice Address - Fax:321-454-2523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-30
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71812207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251358700Medicaid
FL32508Medicare PIN