Provider Demographics
NPI:1356376305
Name:WALL, ROD ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:ROD
Middle Name:ALAN
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 1:2210 SPEAR AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-1646
Mailing Address - Country:US
Mailing Address - Phone:814-539-5340
Mailing Address - Fax:
Practice Address - Street 1:1123 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-4309
Practice Address - Country:US
Practice Address - Phone:814-539-5340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD017369E207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006455980002Medicaid
PAC29507Medicare UPIN
PA090007FKWMedicare ID - Type Unspecified