Provider Demographics
NPI:1982651188
Name:WALLS, TAMARA (MD)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:WALLS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 W ILES AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-4183
Mailing Address - Country:US
Mailing Address - Phone:217-789-0668
Mailing Address - Fax:
Practice Address - Street 1:3050 MONTVALE DR STE A
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-6924
Practice Address - Country:US
Practice Address - Phone:217-726-8096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050161862085R0202X
IL0361110182085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036111018Medicaid
ILK23954Medicare PIN
H81962Medicare UPIN
IL036111018Medicaid