Provider Demographics
NPI:1669474656
Name:WALL, JOHN DOUGLAS (M D)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DOUGLAS
Last Name:WALL
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9304 FOREST POINT CIR
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4700
Mailing Address - Country:US
Mailing Address - Phone:703-368-1969
Mailing Address - Fax:703-369-4164
Practice Address - Street 1:9304 FOREST POINT CIR
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4700
Practice Address - Country:US
Practice Address - Phone:703-368-1969
Practice Address - Fax:703-369-4164
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101044866207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6240259Medicaid
VA6240259Medicaid
E43248Medicare UPIN