Provider Demographics
NPI:1871703785
Name:JAMES F. WALL MD LLC
Entity type:Organization
Organization Name:JAMES F. WALL MD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-917-9094
Mailing Address - Street 1:6608 N. WESTERN AVE
Mailing Address - Street 2:#473
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-7326
Mailing Address - Country:US
Mailing Address - Phone:405-917-9094
Mailing Address - Fax:405-917-9096
Practice Address - Street 1:4301 NW 63RD ST
Practice Address - Street 2:SUITE 205
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-1504
Practice Address - Country:US
Practice Address - Phone:405-917-9094
Practice Address - Fax:405-917-9096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14803207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100032000EMedicaid
OK100032000DMedicaid
OK100032000DMedicaid
OK228723916RMedicare ID - Type Unspecified
OKA100254Medicare PIN
OKD03604Medicare UPIN