Provider Demographics
NPI:1457542961
Name:MONICA J. WALL, M.D., LTD.
Entity Type:Organization
Organization Name:MONICA J. WALL, M.D., LTD.
Other - Org Name:TELEMED AND HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:JAYNE
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-614-4476
Mailing Address - Street 1:PO BOX 530245
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89053-0245
Mailing Address - Country:US
Mailing Address - Phone:702-614-4476
Mailing Address - Fax:702-914-7644
Practice Address - Street 1:3031 W HORIZON RIDGE PKWY STE 120
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-3809
Practice Address - Country:US
Practice Address - Phone:702-614-4476
Practice Address - Fax:702-914-7644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8291261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002002422Medicaid
G47830Medicare UPIN
NV002002422Medicaid