Provider Demographics
NPI:1770651408
Name:WALL, BRANDON JAMES (MD)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:JAMES
Last Name:WALL
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 1:4400 SHUFFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-7100
Mailing Address - Country:US
Mailing Address - Phone:501-686-9300
Mailing Address - Fax:501-686-9576
Practice Address - Street 1:4400 SHUFFIELD AVE
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7100
Practice Address - Country:US
Practice Address - Phone:501-686-9300
Practice Address - Fax:501-686-9576
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-35742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5M489Medicare ID - Type Unspecified
ARH79307Medicare UPIN