Provider Demographics
NPI:1124086426
Name:WALLS, LARRY D (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:WALLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1600 N GRAND AVENUE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2755
Mailing Address - Country:US
Mailing Address - Phone:719-595-7700
Mailing Address - Fax:719-595-7719
Practice Address - Street 1:1600 N GRAND AVENUE
Practice Address - Street 2:SUITE 150
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2755
Practice Address - Country:US
Practice Address - Phone:719-595-7700
Practice Address - Fax:719-595-7719
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16515207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01165158Medicaid
COCO300742Medicare PIN
COD23084Medicare UPIN