Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | E1369 | CA |
Y | 222Z00000X | Podiatrist | E1369 | CA |
NPI | 1043229727 |
---|---|
Provider Name | John W Wall |
First Address | Burbank, CA 91506-2427 |
Second Address | Burbank, CA 91506-2427 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/08/2006 |
Last Update Date | 16/10/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T10918 | (02) | CA |