Provider Demographics
NPI:1356391254
Name:WALL, MARTIN J (DO)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:J
Last Name:WALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:205 GRANDVIEW AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CAMP HILL
Mailing Address - State:PA
Mailing Address - Zip Code:17011-1708
Mailing Address - Country:US
Mailing Address - Phone:717-957-3500
Mailing Address - Fax:
Practice Address - Street 1:211 BROAD ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17053-1302
Practice Address - Country:US
Practice Address - Phone:717-957-3500
Practice Address - Fax:717-957-4069
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-007216-L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014086400001Medicaid
PA391936Medicare Oscar/Certification
739145FMLMedicare ID - Type Unspecified
F53777Medicare UPIN
PA391941Medicare Oscar/Certification