Provider Demographics
NPI:1720393812
Name:WALL, DAVID M (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:M
Last Name:WALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:935 STATE ROUTE 28
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45150-1957
Mailing Address - Country:US
Mailing Address - Phone:513-831-5955
Mailing Address - Fax:513-831-5985
Practice Address - Street 1:935 STATE ROUTE 28
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:OH
Practice Address - Zip Code:45150-1957
Practice Address - Country:US
Practice Address - Phone:513-831-5955
Practice Address - Fax:513-831-5985
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-12
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35095838207V00000X, 208D00000X
UT51418121205207V00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT12170374OtherCAQH
UTFW2154893OtherDEA
UTU00007838Medicare UPIN