Provider Demographics
NPI:1598873440
Name:WALLER, JOHN L (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:WALLER
Suffix:
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 1:206 WESTLAKE PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-8081
Mailing Address - Country:US
Mailing Address - Phone:843-743-9667
Mailing Address - Fax:
Practice Address - Street 1:206 WESTLAKE PARK BLVD
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-8081
Practice Address - Country:US
Practice Address - Phone:843-743-9667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT50236208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC427886Medicaid
D41313Medicare UPIN