Provider Demographics
NPI:1154423754
Name:WALL, BERT PUCKETT (MD)
Entity type:Individual
Prefix:DR
First Name:BERT
Middle Name:PUCKETT
Last Name:WALL
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 1:526 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:BARNESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30204-1713
Mailing Address - Country:US
Mailing Address - Phone:770-358-3284
Mailing Address - Fax:770-358-1015
Practice Address - Street 1:526 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:BARNESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30204-1713
Practice Address - Country:US
Practice Address - Phone:770-358-3284
Practice Address - Fax:770-358-1015
Is Sole Proprietor?:No
Enumeration Date:2006-09-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048003207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00841035GMedicaid
GA52782413003OtherBC / BS
GA52782413003OtherBC / BS
08BBQXBMedicare ID - Type Unspecified