Provider Demographics
NPI:1891714747
Name:WALLER, J. GREGORY (DPM,PC)
Entity Type:Individual
Prefix:DR
First Name:J.
Middle Name:GREGORY
Last Name:WALLER
Suffix:
Gender:M
Credentials:DPM,PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 PAT HARALSON DR
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-8414
Mailing Address - Country:US
Mailing Address - Phone:706-745-6764
Mailing Address - Fax:706-745-7170
Practice Address - Street 1:602 PAT HARALSON DR
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-8414
Practice Address - Country:US
Practice Address - Phone:706-745-6764
Practice Address - Fax:706-745-7170
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000746213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000642672AMedicaid
GA5864600001Medicare NSC
GA48SCBNFMedicare UPIN