Individual
RICHARD EDWIN WALLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1024 MARTIN LUTHER KING DRIVE, MARKS, MS 38646-0289
(662) 326-3502
(662) 326-2555
Mailing address
PO BOX 289, MARKS, MS 38646-0289
(662) 326-3500
(662) 326-7077
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
07067
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00115098
—
MS
Enumeration date
08/15/2006
Last updated
03/01/2017
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