Provider Demographics
NPI:1922501097
Name:WALLER, MARCUS L (DC)
Entity Type:Individual
Prefix:DR
First Name:MARCUS
Middle Name:L
Last Name:WALLER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2923 ALYSON WAY
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-0429
Mailing Address - Country:US
Mailing Address - Phone:708-256-1435
Mailing Address - Fax:
Practice Address - Street 1:901 N POLK ST STE 349
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-4014
Practice Address - Country:US
Practice Address - Phone:214-613-1995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13705111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor