Provider Demographics
NPI:1902801285
Name:WALLER, JAMES DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:DAVID
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:PO BOX 2876
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-2876
Mailing Address - Country:US
Mailing Address - Phone:229-890-5305
Mailing Address - Fax:229-890-5307
Practice Address - Street 1:3004 2ND ST SE
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6797
Practice Address - Country:US
Practice Address - Phone:229-891-9131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA037415207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000565177HMedicaid
GA000565177LMedicaid
GA000565177JMedicaid
GA000565177IMedicaid
GA000565177KMedicaid
GA06BDHQLMedicare ID - Type Unspecified
GA000565177LMedicaid