Provider Demographics
NPI:1871525774
Name:WALLER III, WILLIAM I (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:I
Last Name:WALLER III
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1211 COLUMBIA DR
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061
Mailing Address - Country:US
Mailing Address - Phone:478-452-1780
Mailing Address - Fax:478-452-1786
Practice Address - Street 1:1211 COLUMBIA DR
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061
Practice Address - Country:US
Practice Address - Phone:478-452-1780
Practice Address - Fax:478-452-1786
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA017899207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA017899OtherSTATE LISCENCE
GA017899OtherSTATE LISCENCE
GAD31229Medicare UPIN