Provider Demographics
NPI:1831591312
Name:WALTHALL, JOEL (DO)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:WALTHALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 GUSDORF RD
Mailing Address - Street 2:STE A
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6499
Mailing Address - Country:US
Mailing Address - Phone:575-758-0009
Mailing Address - Fax:575-758-8656
Practice Address - Street 1:50 N PERRY ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342-2217
Practice Address - Country:US
Practice Address - Phone:248-338-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-16
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-2490-21207X00000X
MI5101022441390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery