Provider Demographics
NPI:1528069515
Name:WALLER, WILLIAM CHAMBERS JR (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:CHAMBERS
Last Name:WALLER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5171 CUB LAKE RD
Mailing Address - Street 2:STE B280
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7888
Mailing Address - Country:US
Mailing Address - Phone:928-532-8663
Mailing Address - Fax:928-532-8665
Practice Address - Street 1:2805 5TH ST
Practice Address - Street 2:220
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-6003
Practice Address - Country:US
Practice Address - Phone:605-348-1084
Practice Address - Fax:605-348-3256
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60933481208800000X
SD4033208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY111265100Medicaid
NE460350645Medicaid
SD7500090Medicaid
NE460350645Medicaid
SD7500090Medicaid
WY111265100Medicaid
AZE68289Medicare UPIN