Provider Demographics
NPI:1295747418
Name:WALL, GREGORY CONRAD (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:CONRAD
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 1:7144 AIGNER CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-2301
Mailing Address - Country:US
Mailing Address - Phone:317-875-9255
Mailing Address - Fax:
Practice Address - Street 1:RR 1 BOX 1000
Practice Address - Street 2:
Practice Address - City:LINTON
Practice Address - State:IN
Practice Address - Zip Code:47441-9482
Practice Address - Country:US
Practice Address - Phone:812-847-4471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033829146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant