Provider Demographics
NPI:1861416661
Name:WALL, NORMAN (DO)
Entity type:Individual
Prefix:
First Name:NORMAN
Middle Name:
Last Name:WALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 OLD EUREKA WAY STE 1E
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-0228
Mailing Address - Country:US
Mailing Address - Phone:530-232-3000
Mailing Address - Fax:530-242-8545
Practice Address - Street 1:2701 OLD EUREKA WAY STE 1E
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0228
Practice Address - Country:US
Practice Address - Phone:530-232-3000
Practice Address - Fax:530-242-8545
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA04997207RG0300X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX71800Medicaid
CA00AX71800Medicaid
G96349Medicare UPIN