Provider Demographics
NPI:1003708678
Name:WALL, DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:WALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DOUG
Other - Middle Name:
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:501 S CHERRY ST FL 11
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80246-1325
Mailing Address - Country:US
Mailing Address - Phone:866-839-6979
Mailing Address - Fax:
Practice Address - Street 1:501 S CHERRY ST FL 11
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80246-1325
Practice Address - Country:US
Practice Address - Phone:866-839-6979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-17
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0005418225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist