Provider Demographics
NPI:1811971393
Name:WALL, RICHARD A (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:WALL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2500 W UTOPIA RD
Mailing Address - Street 2:STE. 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-4171
Mailing Address - Country:US
Mailing Address - Phone:623-434-6200
Mailing Address - Fax:623-434-6164
Practice Address - Street 1:19841 N 27TH AVE
Practice Address - Street 2:STE. 101
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-4003
Practice Address - Country:US
Practice Address - Phone:602-942-8512
Practice Address - Fax:602-942-1075
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2013-09-27
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Provider Licenses
StateLicense IDTaxonomies
AZ10250207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ255316Medicaid
AZ86080015085260A099OtherTRIWEST
AZ080088906OtherRAILROAD MEDICARE
AZ86080015085259A529OtherTRIWEST
B44607Medicare UPIN
AZZ28986Medicare PIN