Provider Demographics
NPI:1083888325
Name:WALLS, MICHAEL JASON (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JASON
Last Name:WALLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:560 S LOOP RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3405
Mailing Address - Country:US
Mailing Address - Phone:859-301-2663
Mailing Address - Fax:859-817-7848
Practice Address - Street 1:2845 CHANCELLOR DR
Practice Address - Street 2:
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3418
Practice Address - Country:US
Practice Address - Phone:859-301-2663
Practice Address - Fax:859-817-7848
Is Sole Proprietor?:No
Enumeration Date:2008-04-17
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY42678208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
003031812OtherUNITED HEALTHCARE PROVIDER ID NUMBER
OH0295938Medicaid
KY298418KYIPOtherAETNA BETTER HEALTH OF KENTUCKY PROVIDER ID NUMBER
9318357OtherAETNA PIN
IN300012365Medicaid
CS1811400200OtherCARESOURCE ID
000001148521OtherANTHEM ID
KY15725575OtherWELLCARE OF KENTUCKY PROVIDER ID NUMBER
KY7100086870Medicaid
KYP02011197OtherRAILROAD MEDICARE