Individual
DR. MARK S WALLIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
3535 N FOURTH ST STE 400, LONGVIEW, TX 75605-0038
(903) 757-3881
(903) 757-5948
Mailing address
3535 N FOURTH ST STE 400, LONGVIEW, TX 75605-0038
(903) 757-3881
(903) 757-5948
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
H6685
TX
207ND0101X
MOHS-Micrographic Surgery Physician
Primary
H6685
TX
207ND0900X
Dermatopathology Physician
H6685
TX
207NI0002X
Clinical & Laboratory Dermatological Immunology Physician
H6685
TX
207NP0225X
Pediatric Dermatology Physician
H6685
TX
207NS0135X
Procedural Dermatology Physician
H6685
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
04813881913
MED. ED. NUMBER
TX
05
—
0898678-03
—
TX
01
—
30076724
DPS NUMBER
TX
01
—
45D0684764
CLIA NUMBER
TX
01
—
CID037095
CIDC NUMBER
TX
01
—
H6685
MEDICAL LICENSE NUMBER
TX
Enumeration date
10/03/2005
Last updated
03/07/2023
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