Provider Demographics
NPI:1457424467
Name:WALLER, MITCHELL DEAN (DC)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:DEAN
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 1:3530 S VAL VISTA DR
Mailing Address - Street 2:B105
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-7318
Mailing Address - Country:US
Mailing Address - Phone:480-899-4333
Mailing Address - Fax:480-899-7219
Practice Address - Street 1:3530 S VAL VISTA DR
Practice Address - Street 2:B105
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-7318
Practice Address - Country:US
Practice Address - Phone:480-899-4333
Practice Address - Fax:480-899-7219
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-009141111N00000X
AZ8330111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05527512OtherBCBS
IL05527512OtherBCBS