Provider Demographics
NPI:1841302429
Name:VIRGINIA A. PITTMAN-WALLER, MD, PA
Entity type:Organization
Organization Name:VIRGINIA A. PITTMAN-WALLER, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:ALICIA
Authorized Official - Last Name:PITTMAN-WALLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-826-2626
Mailing Address - Street 1:7959 BROADWAY ST
Mailing Address - Street 2:602
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-2667
Mailing Address - Country:US
Mailing Address - Phone:210-826-2626
Mailing Address - Fax:210-822-4243
Practice Address - Street 1:7959 BROADWAY ST
Practice Address - Street 2:602
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-2667
Practice Address - Country:US
Practice Address - Phone:210-826-2626
Practice Address - Fax:210-822-4243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5666208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty