Provider Demographics
NPI:1699758474
Name:WALL, FORREST P (MD)
Entity type:Individual
Prefix:
First Name:FORREST
Middle Name:P
Last Name:WALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:385 BERT KOUNS INDUSTRIAL LOOP BLDG 100
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-8124
Mailing Address - Country:US
Mailing Address - Phone:318-221-1629
Mailing Address - Fax:
Practice Address - Street 1:385 BERT KOUNS INDUSTRIAL LOOP STE 100
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-8159
Practice Address - Country:US
Practice Address - Phone:318-221-1629
Practice Address - Fax:318-221-6308
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2021-07-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LA10089R2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1650781Medicaid
LA1650781Medicaid
LAF93841Medicare UPIN