Provider Demographics
NPI:1871541862
Name:WALLER, RICHARD EDMUND (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:EDMUND
Last Name:WALLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14355 SOMMERVILLE CT
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113
Mailing Address - Country:US
Mailing Address - Phone:804-379-7721
Mailing Address - Fax:804-379-7699
Practice Address - Street 1:14355 SOMMERVILLE CT
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113
Practice Address - Country:US
Practice Address - Phone:804-379-7721
Practice Address - Fax:804-379-7699
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101040746174400000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010131855Medicaid
VA010131855Medicaid
VAB07504Medicare UPIN