Provider Demographics
NPI:1447288808
Name:WALL, JEFFREY A (DO)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:WALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 STETSON RD
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04210-7813
Mailing Address - Country:US
Mailing Address - Phone:207-784-7388
Mailing Address - Fax:207-795-2043
Practice Address - Street 1:190 STETSON RD
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-7813
Practice Address - Country:US
Practice Address - Phone:207-784-7388
Practice Address - Fax:207-795-2043
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1877207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME048350OtherANTHEM
ME9386763OtherPHCS
ME9759878OtherCIGNA
ME3769958OtherAETNA
ME431799199Medicaid
ME9759878OtherCIGNA
MEME1219Medicare ID - Type Unspecified