Provider Demographics
NPI:1629287222
Name:WALLS, CEDRIC A (MD)
Entity type:Individual
Prefix:
First Name:CEDRIC
Middle Name:A
Last Name:WALLS
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-316-2319
Mailing Address - Fax:704-316-2321
Practice Address - Street 1:8110 HEALTHCARE LOOP
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215
Practice Address - Country:US
Practice Address - Phone:704-316-2319
Practice Address - Fax:704-316-2321
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01073306A207V00000X
NC2018-01059207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201199040Medicaid
IN201199040Medicaid