Provider Demographics
NPI:1528170792
Name:WALL, IAN (DO)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:WALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 QUENTIN RD
Mailing Address - Street 2:SEVENTH FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-2214
Mailing Address - Country:US
Mailing Address - Phone:718-336-3900
Mailing Address - Fax:718-336-3990
Practice Address - Street 1:902 QUENTIN RD
Practice Address - Street 2:SEVENTH FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-2214
Practice Address - Country:US
Practice Address - Phone:718-336-3900
Practice Address - Fax:718-336-3990
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2014-05-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY240806-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400101428Medicare PIN