Individual
CHARLES WALLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
218 BASS LN, BENTON, KY 42025-5824
(270) 556-3239
(270) 354-5865
Mailing address
218 BASS LN, BENTON, KY 42025-5824
(270) 556-3239
(270) 354-5865
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
29738
KY
208D00000X
General Practice Physician
Primary
29738
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
4047217
—
TN
05
—
64297385
—
KY
Enumeration date
06/16/2005
Last updated
02/01/2017
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