Provider Demographics
NPI:1124109210
Name:WALLER, SUSAN J (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:J
Last Name:WALLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 91734
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23291-1734
Mailing Address - Country:US
Mailing Address - Phone:804-358-6100
Mailing Address - Fax:804-342-7619
Practice Address - Street 1:1250 E MARSHALL STREET
Practice Address - Street 2:PSYCHIATRY
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-0510
Practice Address - Country:US
Practice Address - Phone:804-828-2000
Practice Address - Fax:804-827-4998
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012385142084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010205662 541581185Medicaid
VAI43464Medicare UPIN
VA008708M94 C03694Medicare ID - Type Unspecified